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    Chief Complaint: Problem Visit

    Uploaded by

    Chirra Williams
    AAP Problem Visit Document

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Chief Complaint: Problem Visit

    Uploaded by

    Chirra Williams
    101 views2 pages
    AAP Problem Visit Document

    Original Title

    Problem Visit

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    © © All Rights Reserved

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    AAP Problem Visit Document

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views2 pages

    Chief Complaint: Problem Visit

    Uploaded by

    Chirra Williams
    AAP Problem Visit Document

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ACCOMPANIED BY

    PREFERRED LANGUAGE DATE/TIME Name

    DRUG ALLERGIES CURRENT MEDICATIONS ID NUMBER

    WEIGHT (%) HEIGHT (%) BMI (%) TEMPERATURE BIRTH DATE AGE M F NURSE SIGNATURE

    See growth chart.

    TEMP AX R O T RESP PULSE BP SpO2


    Chief Complaint

    Immunization current for age Yes No See Immunization Record.

    History (location, timing, quality, severity, context, or modifying factors)


    Yes No Days
    Fever (max )
    Cough
    Nasal congestion
    Sore throat
    Earache R L
    Vomiting
    Diarrhea
    Abdominal pain
    Headache
    Rash
    Wheeze

    Review of Systems
    Problem List No interval change
    Past medical history (see Initial History Questionnaire) No interval change
    Pertinent negatives

    Social/Family History
    See Initial History Questionnaire. No interval change

    Physical Examination
     Examined and normal Findings and comments related to chief complaint.
    GENERAL APPEARANCE NEUROLOGIC
    NECK HEAD
    RESPIRATORY EYES
    CARDIOVASCULAR EARS, NOSE, MOUTH, AND THROAT
    GASTROINTESTINAL CHEST
    GENITOURINARY BACK
    GENITALIA MUSCULOSKELETAL
    EXTREMITIES MENTAL STATUS
    SKIN

    Diagnosis

    Plan
    Print Name Signature
    See other side PROVIDER 1

    Follow-up/Next visit PRN days/weeks/months


    PROVIDER 2

    HE0429 Problem Visit


    The recommendations in this publication do not indicate an exclusive course of treatment or serve as
    a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
    Copyright © 2010 American Academy of Pediatrics. All rights reserved. No part of this publication may
    be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
    mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

    HE0429  9-208/1208

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