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