Healthcare Record
A. Patient Information
Full Name: Jeremy Marvin
Date of Birth: 01/15/2050
Gender: Male
Address: Omaha, NE 68101
Phone Number: 222 555 7777
Email: jeremy@you.mail
Insurance Provider: FutureCare Health Insurance
Policy Number: FC-987654321
B. Visit Information
Date of Visit: 03/01/2080
Time of Visit: 10:30 AM
Reason for Visit: Annual check-up and persistent fatigue
Provider Name: Dr. Emily Carter
Provider Specialty: Primary Care Physician
C. Medical History
Allergies:
Chronic Conditions:
Surgeries:
Medications:
D. Vital Signs
Vital Sign | Measurement | Normal Range |
|---|
Blood Pressure | 140/90 mmHg | <120/80 mmHg |
Heart Rate | 82 bpm | 60-100 bpm |
Respiratory Rate | 18 breaths/min | 12-20 breaths/min |
Temperature | 98.6°F | 97-99°F |
Weight | 190 lbs | Varies by individual |
Height | 5'10" | — |
BMI | 27.3 | 18.5-24.9 |
E. Assessment
Diagnosis: Hypertension (ICD-10: I10), Fatigue (ICD-10: R53.83)
Findings: Elevated blood pressure and borderline overweight BMI. Patient reports consistent fatigue over the last three months. No signs of infection or acute illness.
Tests Ordered:
F. Treatment Plan
Medications Prescribed:
Follow-Up Visits:
Lifestyle Recommendations:
Referrals:
G. Notes and Additional Information
Patient expresses concern about managing stress due to work. Counseling for stress management is recommended if symptoms persist.
Prepared By: [YOUR NAME], Medical Records Specialist
Date of Preparation: 03/01/2080
This record is confidential and intended for medical purposes only.
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