Patient Chart Patient Demographics Name: DOB: ID Verified? Address: Email: Cell #: Pharmacy: Insurance: Memb. ID: Questionnaires + Questionnaire Score Date Allergies + Allergies Reaction Severity Mild Moderate Severe Mild Moderate Severe History of Present Illness Provider: William Kelly, FNP-C Kaitlyn Almeida, PA-C Reason for visit: ADHD f/u New ADHD AWE Other Medical Chief Complaint: HPI: Immunizations + Vaccine Last Given Due Medications Medication Dose Sig Date Rx Labs & Imaging Date Done? Labs Abnormals Chronic Conditions Chronic Conditions Health Maintenance STI testing Colon CA Cholesterol DM Cervical CA Last Dental Exam Last Eye Exam Last OBGYN Appt TBD TBD Medical/Family History Medical History Medical Problems Healthcare Team Hospitalizations ER Visits Surgical Hx Supplements & Herbs Family History Mother Father Siblings Children Other Family Social History Social Details General Occupation Sexual orientation / gender Identity Relationship Status Exercise Diet Substance Use Caffeine Alcohol Tobacco Marijuana Illicit Drugs
