brevaAdult annual physical
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
Interval history
Patient concerns and goals for the visit: [ ] Changes in health, hospital or specialist care since last visit: [ ] Current medications, supplements and allergies reviewed: [ ] Family history updates: [ ]
Risk review
Tobacco, alcohol and substance use as reported: [ ] Physical activity, diet and sleep as reported: [ ] Depression screening tool and result if performed: [ ] Other screening questionnaires and results: [ ]
Preventive services
Screenings completed, with dates and sources: [ ] Screenings due or overdue and decisions made: [ ] Immunizations reviewed, given today or declined: [ ]
Examination
Vitals measured today, with units: [ ] Examination performed and findings: [ ]
Assessment and plan
Preventive recommendations and patient decisions: [ ] Problems addressed today, documented separately: [ ] Orders and referrals: [ ] Counseling provided: [ ]
Follow-up
Follow-up timing and purpose: [ ] Return precautions discussed: [ ] Patient questions and understanding: [ ]