patient history and physical examination report sample

What should be included in a physical exam of a patient?

The physician should ask specifically about symptoms that suggest cardiovascular, pulmonary, musculoskeletal, and neuropsychiatric disorders. Symptoms suggestive of infection with any of the excludable communicable diseases (tuberculosis, syphilis, gonorrhea, and Hansen’s disease) should also be sought.

What is a Class A physical examination?

a physical examination, including an evaluation of mental status, sufficient to permit a determination of the presence and the severity of Class A and Class B conditions. The physical examination is to include:

What is the medical report form for the consulting physician?

The report of the consulting physician, as received by the panel physician, must be included with the medical report form. The medical report form is to be completed in English, typed, dated, and signed by the panel physician.

How do you write a medical report for a mental illness?

Findings of physical and mental disorders should be entered in the “Remarks” section of the medical report form. The panel physician must include a statement of likely degree of disability and the need for extensive medical care or institutionalization for any Class B conditions identified during the examination.

What is a physical exam?

a physical examination, including an evaluation of mental status, sufficient to permit a determination of the presence and the severity of Class A and Class B conditions. The physical examination is to include: a mental status examination that includes, at a minimum, assessment of intelligence, thought, cognition (comprehension), judgment, ...

What is the medical report form?

The Medical Report Form. The Centers for Disease Control and Prevention (CDC), United States Public Health Service (PHS), is responsible for ensuring that aliens entering the United States do not pose a threat to the public health of this country. The visa medical examination is one means of evaluating the health of aliens applying ...

What is the purpose of a medical exam for a visa?

The purpose of the visa medical examination is to determine whether the alien has: 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for a visa (Class A condition); or 2) a physical or mental disorder that , although does not constitute a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person’s ability to care for him- or herself, to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

What is the responsibility of a panel physician?

The responsibility of the panel physician is only to conduct the examination and testing required to determine the alien’s status regarding Class A and Class B conditions and to complete the medical report form. If the examination reveals an acute illness that makes it impossible to determine the alien’s medical status regarding Class A or B conditions, the acute illness should be treated by a physician of the alien’s choice, and the visa medical examination process completed when the alien has recovered. If the alien needs further evaluation or treatment for conditions not relevant to the visa medical examination, the physician should advise the alien of this and make recommendations for appropriate diagnostic evaluation and treatment.

What is a mental exam?

a physical examination, including an evaluation of mental status, sufficient to permit a determination of the presence and the severity of Class A and Class B conditions. The physical examination is to include:#N#a mental status examination that includes, at a minimum, assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), and behavior#N#a physical examination that includes, at a minimum, examination of the eyes, ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, and skin#N#all diagnostic tests required to identify communicable diseases of public health significance, as well as other tests identified as necessary to confirm a suspected diagnosis of any other Class A or Class B condition. 1 a mental status examination that includes, at a minimum, assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), and behavior 2 a physical examination that includes, at a minimum, examination of the eyes, ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, and skin 3 all diagnostic tests required to identify communicable diseases of public health significance, as well as other tests identified as necessary to confirm a suspected diagnosis of any other Class A or Class B condition.

What diseases should be asked by a physician?

The physician should ask specifically about symptoms that suggest cardiovascular, pulmonary, musculoskeletal, and neuropsychiatric disorders. Symptoms suggestive of infection with any of the excludable communicable diseases (tuberculosis, syphilis, gonorrhea, and Hansen’s disease) should also be sought.

What section of medical report should you indicate drug abuse?

Findings of drug abuse or addiction should be indicated in the “Remarks” section of the medical report form. The panel physician should indicate the specific drug that is/was being used and the last time it was used if the patient has discontinued its use.