Medical Record Sheet
PATIENT INFORMATION
Field | Details |
|---|
Patient Name | Jonatan Farrell |
Date of Birth (MM/DD/YYYY) | 07/15/2055 |
Gender | Male |
Address | Cincinnati, OH 45201 |
Phone Number | 222 555 7777 |
Emergency Contact Name | Jane Farrell |
Emergency Contact Phone Number | 222 555 7777 |
Relationship to Patient | Spouse |
MEDICAL HISTORY
Field | Details |
|---|
Primary Care Physician | Dr. [YOUR NAME], MD |
Current Medications | Astrovent 20 mg, once daily
OmegaCaps 5,000 IU, every evening |
Allergies | Penicillin
Shellfish |
Chronic Conditions | Type 2 Diabetes
Hypertension |
Surgical History | Appendectomy (2070)
Laser Cataract Surgery (2085) |
Family Medical History | Father: Coronary Artery Disease
Mother: Type 2 Diabetes |
CURRENT VISIT DETAILS
Field | Details |
|---|
Date of Visit | 12/03/2090 |
Reason for Visit/Chief Complaint | Persistent fatigue and shortness of breath |
Symptoms (Duration, Severity, etc.) | |
Vitals | Blood Pressure: 145/92 mmHg
Heart Rate: 88 bpm
Temperature: 98.6°F (37°C)
Weight: 190 lbs (86.18 kg)
Height: 5’10” (177.8 cm) |
ASSESSMENT & PLAN
Field | Details |
|---|
Diagnosis | Likely anemia, pending lab confirmation |
Treatment Plan | Order complete blood count (CBC) and iron studies Recommend dietary adjustments to increase iron intake Schedule follow-up in two weeks
|
Medications Prescribed | Iron Supplements 325 mg, once daily |
Follow-Up Instructions | Monitor energy levels and report any worsening symptoms |
Specialist Referrals | Hematologist |
NOTES
Patient exhibits pale skin; no signs of acute distress.
Physician’s Name: Dr. [YOUR NAME], MD
Date: 12/03/2090
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