Project Summary: Physical Assessment Paper ________________ GUIDELINES FOR WRITTEN PHYSICAL EVALUATION PAPERS ADULT EVALUATION 1. Patient Identification Age/DOB; Race; Sex; Religion; Occupation 2. Past Medical History (PMH)- (5 POINTS) Illnesses; Surgeries/Procedures; Childhood Illnesses; Trauma; Most Recent Physical Examination; LMP 3. Medications- (5 POINTS) Prescription and OTC dose and frequency 4. Allergies- (2 POINTS) Medication, Food and Environmental clarify what kind of reaction 5. Social History- (3 POINT) Tobacco; Alcohol; Caffeine; Recreational Drug Use 6. Immunizations and Travel- (1 POINT) 7. Family History (FHx)- (4 POINTS) Marital Status; Parents (living, dead, cause of death); family illnesses 8. Review of Systems: (this is told by the patient during the interview)- (15 POINTS) General; Head, Ears, Eyes, Nose, Throat; Pulmonary; Cardiac; Gastrointestinal; Genitourinary; Musculoskeletal; Vascular; Endocrine; Blood; Integumentary; Psychological 9. Physical Examination: (this is what the examiner observes)- (15 POINTS) General Appearance; VS; HEENT; Neck; Lymph Nodes; Breast; Respiratory/Thorax; Cardiac; Abdomen; GU (not required for this course- write EXAM DEFERRED); Rectal(not required for this course-write EXAM DEFERRED); Vascular/Pulse; Musculoskeletal; Neurological (including cranial nerves I-XII, Motor, Coordination, Sensory, Reflexes) _____________ APA format and reference page