Administrative Medical Assisting a Workforce Readiness Approach 1st Edition by Helen Houser, Terri Wyman

Exercise 8

Photocopy the blank combination medical history and physical examination form shown in Figure 15-4. Fill out the form by using the following patient information:
For medical history section: Date: 2/14/12; the patient is Heather R. MacEntee, age 35, living at 344 Westwind Lane, Apartment 28, Round Tree, IL 60012; telephone [phone]. She is a real estate broker, married, with a 6-yearold child. Her father died at age 55; her mother is 62 and has congestive heart disease. She has no siblings. The family has a history of heart disease and diabetes. The patient had chickenpox and mumps at age 7 and surgery for an ovarian cyst at 22. She has an allergy to ragweed but is not taking any medications at present.
For physical examination section:
Ms. MacEntee weighs 142 lb, is 5 ft 10 in tall, and her temperature and respiration are normal. Her pulse is 74, her blood pressure is 110/75, and her chest sounds are normal.
Her chief complaint is discomfort in the area of the gallbladder. She has intense pain after eating. Blood tests are normal. The doctor's initial impression is suspected gallstones, and an ultrasound scan of the gallbladder is ordered. Treatment plan depends on the scan results.