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Patient Name *
Title
General Appearance
Weight
.g., 70 kg
Height
e.g., 170 cm
Body Mass Index (BMI)
[Calculated Field] based on weight and height
Subject Of Visit
Service
Heart Rate
Heart Sounds
Peripheral Pulses
Breath Sounds
Respiratory Rate
Chest Expansion
Abdominal Examination
Mental Status
Sensory Function
Range of Motion
Ear Examination
Thyroid
Bladder
Bowel Sounds
Cranial Nerves
Joint Examination
Skin
Nasal Passage
Genitalia
Other Glands
Liver and Spleen Size
Motor Function
Muscle Strength
Nails
Throat
Kidney
Mood
Thought Process
Blood Pressure
e.g., 120/80 mmHg
Respiratory Rate
e.g., 16 breaths/min
Heart Rate
e.g., 72 bpm
Oxygen Saturation
e.g., 98%
Temperature
e.g., 98.6°F or 37°C
Main Complaint
Symptom Description
Symptoms
Duration of Symptoms
Severity of Symptoms
Sugar
Possible Conditions
Differential Diagnosis
Lab Results
Recommended Tests
Medication Prescribed
Referral to Specialist
Follow-up Appointment
Additional Observations