Skip to Main Content

COLLECT

| Download (.pdf) | Print
Patient Initials: Age DOB Gender
       
Race Height (in)/(cm) Weight (lb)/(kg) BMI
       
Chief Complaint (CC)
 

Past Medical History (PMH)

(Must have at least two medical conditions and one must be cardiac related)

 
Adverse Drug Events or Allergies
Drug, excipient, or allergen Reaction Information source (ie, patient, caregiver, chart)
     
     
     
Pertinent Family History
 
Marital Status (M/S/D/W)  
Tobacco (No/Describe)  
Alcohol (No/Describe)  
Illicit Drug Use (No/Describe)  
Diet (Describe)  
Exercise and fall history (Describe)  

Patient-Stated and Profile-Listed Medications: (Must be on at least 5 and not more than 12)

| Download (.pdf) | Print
Medication #1 Strength Form Qty Route Frequency Last fill date
Lisinopril 10mg Tabs 1 PO Daily 01/01/2017
Patient-Stated Indication Hypertension Is med on Rx profile? Y
Medication #2 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #3 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #4 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #5 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #6 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #7 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #8 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #9 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  
Medication #10 Strength Form Qty Route Frequency Last fill date
             
Patient-Stated Indication   Is med on Rx profile?  

Herbal Products and OTCs

| Download (.pdf) | Print
Product Name Strength Form Qty Route Frequency Patient-Stated Indication
             
             
             
             
             

Review of Systems

| Download (.pdf) | Print
General  
Cardiovascular  

Pertinent Labs

...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.