"Upper Lower Respiratory Infections Form"

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Upper/Lower Respiratory Infections
Subjective Data
Patient Name:
Date:
Age:
Pregnant:
Yes
No/Unlikely
Asthma:
Yes
No
Tobacco Use:
Daily
Weekly
Occasionally
Never
Alcohol Consumption:
Daily
Weekly
Occasionally
Never
Allergies:
Current Medication:
Headaches:
Yes
No
Duration:
Chills/Sweat:
Yes
No
Duration:
Fatigue:
Yes
No
Duration:
Myalgia:
Yes
No
Duration:
Nausea:
Yes
No
Duration:
Vomiting:
Yes
No
Duration:
Chest Pains:
Yes
No
Symptoms:
Throat Issues:
Yes
No
Symptoms:
Nose Issues:
Yes
No
Symptoms:
Eye Issues:
Yes
No
Symptoms:
Ear Issues:
Yes
No
Symptoms:
Other:
Yes
No
Symptoms:
Objective Data
BP:
P:
T:
Vitals
Weight:
Other:
Eyes:
Ears:
Nose:
Skin:
Neck:
Lungs:
Heart:
Throat:
Assessment
Plan for Treatment
Signature
Date
www.FreePrintableMedicalForms.com
Upper/Lower Respiratory Infections
Subjective Data
Patient Name:
Date:
Age:
Pregnant:
Yes
No/Unlikely
Asthma:
Yes
No
Tobacco Use:
Daily
Weekly
Occasionally
Never
Alcohol Consumption:
Daily
Weekly
Occasionally
Never
Allergies:
Current Medication:
Headaches:
Yes
No
Duration:
Chills/Sweat:
Yes
No
Duration:
Fatigue:
Yes
No
Duration:
Myalgia:
Yes
No
Duration:
Nausea:
Yes
No
Duration:
Vomiting:
Yes
No
Duration:
Chest Pains:
Yes
No
Symptoms:
Throat Issues:
Yes
No
Symptoms:
Nose Issues:
Yes
No
Symptoms:
Eye Issues:
Yes
No
Symptoms:
Ear Issues:
Yes
No
Symptoms:
Other:
Yes
No
Symptoms:
Objective Data
BP:
P:
T:
Vitals
Weight:
Other:
Eyes:
Ears:
Nose:
Skin:
Neck:
Lungs:
Heart:
Throat:
Assessment
Plan for Treatment
Signature
Date
www.FreePrintableMedicalForms.com