Patient's Initial Assessment Report: Example 1
Patient Initial Assessment Report Patient Information: Name: John Doe Age: 45 Gender: Male Date of Birth: June 12, 1979 Contact Number: (555) 123-4567 Address: 123 Elm Street, Springfield, IL 62701 Referral Source: Referring Physician: Dr. Jane Smith Reason for Referral: Evaluation of persistent chest pain Presenting Complaint: Chief Complaint: Persistent chest pain for the past two weeks Description of Pain: Dull, aching pain in the left side of the chest; occasional sharp pain radiating to the left arm Medical History: Past Medical History: Hypertension (diagnosed 5 years ago) Type 2 Diabetes Mellitus (diagnosed 3 years ago) Hyperlipidemia Surgical History: Appendectomy (2005) Allergies: No known drug allergies Medications: Lisinopril 20 mg daily Metformin 500 mg twice daily Atorvastatin 10 mg daily Family History: Father: Deceased (age 65) - Myocardial infarction Mother: Age 70 - Hypertension, Type 2 Diabetes Mellitus Social History: Occupation: Office Manager Smoking: 1...