DEPARTMENT OF FAMILY & COMMUNITY MEDICINE

Student Name: Preceptor Name:
Rotation:
Date Patient Seen:    mm/dd/yy   
Age:
Newborn (0-11 mo)
Pediatrics (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)
Geriatric (65+ years)
Patient's Gender: Male      Female
Type of Problem:
Acute
Chronic
Health Maintenance 
Location:
Clinic Nursing Home
ER Out-Patient Surgery
Home Visit Other
In-Patient    
 

NOTE:  Bold = "must see"

Diagnosis 1:

(select only one)

(counts toward quota)

 

Abdominal Pain Infant or Child Health Check / Routine
Acne Inflammatory Bowel Disease
Alcoholism Influenza with Other Respiratory Manifestations
Allergies/Rhinitis Ingrown Toenail
Alzheimer's Disease Kidney Disease
Anemia Knee pain/injuries
Angina Labyrinthitis
Ankle pain/injuries Laceration
Anxiety States Lightheadedness
Arthritis - Unspecified Lipoma
Asthma/Wheeze Lumbar pain/Lumbar strain
Atrial Fibrillation Menopause
Attention Deficit Disorder / Hyperactivity Menstrual Disorder
Bell's Palsy Migraine
Benign Prostatic Hypertrophy Mitral Valve Prolapse
Bronchitis Mono
Burn Musculoskeletal Pain - Other
Cancer - Specific Type MVA
Cancer Screening Myocardial Infarction (Heart Attack)
Carpal Tunnel Syndrome Neck Sprain/Strain
CAD/Chest Pain Obesity
Cellulitis Onycomycosis
Chest Pain/CAD Osteoarthritis
Cholecystitis Osteoporosis
Chronic Obstructed Pulmonary Disease/Cough Otitis Media/Ear Pain
Cirrhosis Parkinson's Disease
Congestive Heart Failure/Edema Pelvic Inflammatory Disease
Conjunctivitis/Red Eye/Eye Pain Peptic Ulcer Disease
Constipation/Diarrhea/impaction Pharyngitis
Contact Dermatitis and Other Eczema Plantar Fasciitis
Contraceptive visit Pneumonia
Cough/Chronic Obstructed Pulmonary Disease Poison Ivy
Croup Prenatal Visit/Pregnancy
CVA/Stroke/Vertigo Pregnancy/Prenatal Visit
Deep Vein Thromobosis Pyelonephritis
Delerium/Dementia Rash
Dementia/Delerium Red Eye/Conjunctivitis/Eye Pain
Depressive Disorders Rhinitis/Allergies
Diabetes Mellitus Ringworm
Diarrhea/constipation/impaction Rosacea
Diverticulosis School Physical
Dyspepsia/GERD Seizures
Dysplastic Nevi Shingles
Dyspnea Shoulder pain/injuries
Ear Pain/Otitis Media Sinusitis
Edema/Congestive Heart Failure Skin lesions
Elbow pain/injuries Skin Tags
Elevated Blood Pressure Smoking/Tobacco
Erectile dysfunction Sports Physical
Eye Pain/Conjunctivitis/Red Eye Sprains/Strains - Other
Fatigue STD
Fever of unknown origin Stroke/CVA/Vertigo
Fracture - Specific Location Substance Use/Abuse
Ganglion Cyst Sunburn
Gastritis and Gastroduodenitis Syncope
Gastroenteritis and Colitis Tendonitis
General Medical Exam, well child exam, well adult exam, physicals Tennis Elbow
GERD/Dyspepsia Tinea Pedis
Gynecological Examination Tobacco/Smoking
H. Pylori Tonsillitis
Headache - Unspecified Unspecified Viral and Chlamydial Infections
Health Examination of Defined Subpopulations Upper Respiratory Infection
Heart Attack (Myocardial Infarction) Urinary Tract Infection
Hemorrhoids Vaginal Candidiasis
Hip pain/injuries Vaginitis
Hyperactivity/Attention Deficit Disorder Vaginosis
Hypercholesterolemia Vertigo/Stroke/CVA
Hyperlipidemia - Other and Unspecified Warts
Hypertension/Essential Wheeze/Asthma
Hyperthyroidism Wrist pain/injuries
Hypothyroidism    
Immunization    
Impaction/Constipation/Diarrhea Other: 
Diagnosis 2:

(select only one)

(counts toward quota)

 

*None Infant or Child Health Check / Routine
Abdominal Pain Inflammatory Bowel Disease
Acne Influenza with Other Respiratory Manifestations
Alcoholism Ingrown Toenail
Allergies/Rhinitis Kidney Disease
Alzheimer's Disease Knee pain/injuries
Anemia Labyrinthitis
Angina Laceration
Ankle pain/injuries Lightheadedness
Anxiety States Lipoma
Arthritis - Unspecified Lumbar pain/Lumbar strain
Asthma/Wheeze Menopause
Atrial Fibrillation Menstrual Disorder
Attention Deficit Disorder / Hyperactivity Migraine
Bell's Palsy Mitral Valve Prolapse
Benign Prostatic Hypertrophy Mono
Bronchitis Musculoskeletal Pain - Other
Burn MVA
Cancer - Specific Type Myocardial Infarction (Heart Attack)
Cancer Screening Neck Sprain/Strain
Carpal Tunnel Syndrome Obesity
CAD/Chest Pain Onycomycosis
Cellulitis Osteoarthritis
Chest Pain/CAD Osteoporosis
Cholecystitis Otitis Media/Ear Pain
Chronic Obstructed Pulmonary Disease/Cough Parkinson's Disease
Cirrhosis Pelvic Inflammatory Disease
Congestive Heart Failure/Edema Peptic Ulcer Disease
Conjunctivitis/Red Eye/Eye Pain Pharyngitis
Constipation/Diarrhea/impaction Plantar Fasciitis
Contact Dermatitis and Other Eczema Pneumonia
Contraceptive visit Poison Ivy
Cough/Chronic Obstructed Pulmonary Disease Prenatal Visit/Pregnancy
Croup Pregnancy/Prenatal Visit
CVA/Stroke/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Delerium/Dementia Red Eye/Conjunctivitis/Eye Pain
Dementia/Delerium Rhinitis/Allergies
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diarrhea/constipation/impaction School Physical
Diverticulosis Seizures
Dyspepsia/GERD Shingles
Dysplastic Nevi Shoulder pain/injuries
Dyspnea Sinusitis
Ear Pain/Otitis Media Skin lesions
Edema/Congestive Heart Failure Skin Tags
Elbow pain/injuries Smoking/Tobacco
Elevated Blood Pressure Sports Physical
Erectile dysfunction Sprains/Strains - Other
Eye Pain/Conjunctivitis/Red Eye STD
Fatigue Stroke/CVA/Vertigo
Fever of unknown origin Substance Use/Abuse
Fracture - Specific Location Sunburn
Ganglion Cyst Syncope
Gastritis and Gastroduodenitis Tendonitis
Gastroenteritis and Colitis Tennis Elbow
General Medical Exam, well child exam, well adult exam, physicals Tinea Pedis
GERD/Dyspepsia Tobacco/Smoking
Gynecological Examination Tonsillitis
H. Pylori Unspecified Viral and Chlamydial Infections
Headache - Unspecified Upper Respiratory Infection
Health Examination of Defined Subpopulations Urinary Tract Infection
Heart Attack (Myocardial Infarction) Vaginal Candidiasis
Hemorrhoids Vaginitis
Hip pain/injuries Vaginosis
Hyperactivity/Attention Deficit Disorder Vertigo/Stroke/CVA
Hypercholesterolemia Warts
Hyperlipidemia - Other and Unspecified Wheeze/Asthma
Hypertension/Essential Wrist pain/injuries
Hyperthyroidism    
Hypothyroidism    
Immunization Other: 
Impaction/Constipation/Diarrhea    
Diagnosis 3:

(select only one)

(counts toward quota)

 

*None Infant or Child Health Check / Routine
Abdominal Pain Inflammatory Bowel Disease
Acne Influenza with Other Respiratory Manifestations
Alcoholism Ingrown Toenail
Allergies/Rhinitis Kidney Disease
Alzheimer's Disease Knee pain/injuries
Anemia Labyrinthitis
Angina Laceration
Ankle pain/injuries Lightheadedness
Anxiety States Lipoma
Arthritis - Unspecified Lumbar pain/Lumbar strain
Asthma/Wheeze Menopause
Atrial Fibrillation Menstrual Disorder
Attention Deficit Disorder / Hyperactivity Migraine
Bell's Palsy Mitral Valve Prolapse
Benign Prostatic Hypertrophy Mono
Bronchitis Musculoskeletal Pain - Other
Burn MVA
Cancer - Specific Type Myocardial Infarction (Heart Attack)
Cancer Screening Neck Sprain/Strain
Carpal Tunnel Syndrome Obesity
CAD/Chest Pain Onycomycosis
Cellulitis Osteoarthritis
Chest Pain/CAD Osteoporosis
Cholecystitis Otitis Media/Ear Pain
Chronic Obstructed Pulmonary Disease/Cough Parkinson's Disease
Cirrhosis Pelvic Inflammatory Disease
Congestive Heart Failure/Edema Peptic Ulcer Disease
Conjunctivitis/Red Eye/Eye Pain Pharyngitis
Constipation/Diarrhea/impaction Plantar Fasciitis
Contact Dermatitis and Other Eczema Pneumonia
Contraceptive visit Poison Ivy
Cough/Chronic Obstructed Pulmonary Disease Prenatal Visit/Pregnancy
Croup Pregnancy/Prenatal Visit
CVA/Stroke/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Delerium/Dementia Red Eye/Conjunctivitis/Eye Pain
Dementia/Delerium Rhinitis/Allergies
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diarrhea/constipation/impaction School Physical
Diverticulosis Seizures
Dyspepsia/GERD Shingles
Dysplastic Nevi Shoulder pain/injuries
Dyspnea Sinusitis
Ear Pain/Otitis Media Skin lesions
Edema/Congestive Heart Failure Skin Tags
Elbow pain/injuries Smoking/Tobacco
Elevated Blood Pressure Sports Physical
Erectile dysfunction Sprains/Strains - Other
Eye Pain/Conjunctivitis/Red Eye STD
Fatigue Stroke/CVA/Vertigo
Fever of unknown origin Substance Use/Abuse
Fracture - Specific Location Sunburn
Ganglion Cyst Syncope
Gastritis and Gastroduodenitis Tendonitis
Gastroenteritis and Colitis Tennis Elbow
General Medical Exam, well child exam, well adult exam, physicals Tinea Pedis
GERD/Dyspepsia Tobacco/Smoking
Gynecological Examination Tonsillitis
H. Pylori Unspecified Viral and Chlamydial Infections
Headache - Unspecified Upper Respiratory Infection
Health Examination of Defined Subpopulations Urinary Tract Infection
Heart Attack (Myocardial Infarction) Vaginal Candidiasis
Hemorrhoids Vaginitis
Hip pain/injuries Vaginosis
Hyperactivity/Attention Deficit Disorder Vertigo/Stroke/CVA
Hypercholesterolemia Warts
Hyperlipidemia - Other and Unspecified Wheeze/Asthma
Hypertension/Essential Wrist pain/injuries
Hyperthyroidism    
Hypothyroidism    
Immunization Other: 
Impaction/Constipation/Diarrhea    
Diagnosis 4:

(select only one)

(counts toward quota)

 

*None Infant or Child Health Check / Routine
Abdominal Pain Inflammatory Bowel Disease
Acne Influenza with Other Respiratory Manifestations
Alcoholism Ingrown Toenail
Allergies/Rhinitis Kidney Disease
Alzheimer's Disease Knee pain/injuries
Anemia Labyrinthitis
Angina Laceration
Ankle pain/injuries Lightheadedness
Anxiety States Lipoma
Arthritis - Unspecified Lumbar pain/Lumbar strain
Asthma/Wheeze Menopause
Atrial Fibrillation Menstrual Disorder
Attention Deficit Disorder / Hyperactivity Migraine
Bell's Palsy Mitral Valve Prolapse
Benign Prostatic Hypertrophy Mono
Bronchitis Musculoskeletal Pain - Other
Burn MVA
Cancer - Specific Type Myocardial Infarction (Heart Attack)
Cancer Screening Neck Sprain/Strain
Carpal Tunnel Syndrome Obesity
CAD/Chest Pain Onycomycosis
Cellulitis Osteoarthritis
Chest Pain/CAD Osteoporosis
Cholecystitis Otitis Media/Ear Pain
Chronic Obstructed Pulmonary Disease/Cough Parkinson's Disease
Cirrhosis Pelvic Inflammatory Disease
Congestive Heart Failure/Edema Peptic Ulcer Disease
Conjunctivitis/Red Eye/Eye Pain Pharyngitis
Constipation/Diarrhea/impaction Plantar Fasciitis
Contact Dermatitis and Other Eczema Pneumonia
Contraceptive visit Poison Ivy
Cough/Chronic Obstructed Pulmonary Disease Prenatal Visit/Pregnancy
Croup Pregnancy/Prenatal Visit
CVA/Stroke/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Delerium/Dementia Red Eye/Conjunctivitis/Eye Pain
Dementia/Delerium Rhinitis/Allergies
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diarrhea/constipation/impaction School Physical
Diverticulosis Seizures
Dyspepsia/GERD Shingles
Dysplastic Nevi Shoulder pain/injuries
Dyspnea Sinusitis
Ear Pain/Otitis Media Skin lesions
Edema/Congestive Heart Failure Skin Tags
Elbow pain/injuries Smoking/Tobacco
Elevated Blood Pressure Sports Physical
Erectile dysfunction Sprains/Strains - Other
Eye Pain/Conjunctivitis/Red Eye STD
Fatigue Stroke/CVA/Vertigo
Fever of unknown origin Substance Use/Abuse
Fracture - Specific Location Sunburn
Ganglion Cyst Syncope
Gastritis and Gastroduodenitis Tendonitis
Gastroenteritis and Colitis Tennis Elbow
General Medical Exam, well child exam, well adult exam, physicals Tinea Pedis
GERD/Dyspepsia Tobacco/Smoking
Gynecological Examination Tonsillitis
H. Pylori Unspecified Viral and Chlamydial Infections
Headache - Unspecified Upper Respiratory Infection
Health Examination of Defined Subpopulations Urinary Tract Infection
Heart Attack (Myocardial Infarction) Vaginal Candidiasis
Hemorrhoids Vaginitis
Hip pain/injuries Vaginosis
Hyperactivity/Attention Deficit Disorder Vertigo/Stroke/CVA
Hypercholesterolemia Warts
Hyperlipidemia - Other and Unspecified Wheeze/Asthma
Hypertension/Essential Wrist pain/injuries
Hyperthyroidism    
Hypothyroidism    
Immunization Other: 
Impaction/Constipation/Diarrhea    
Diagnosis 5:

(select only one)

(counts toward quota)

 

*None Infant or Child Health Check / Routine
Abdominal Pain Inflammatory Bowel Disease
Acne Influenza with Other Respiratory Manifestations
Alcoholism Ingrown Toenail
Allergies/Rhinitis Kidney Disease
Alzheimer's Disease Knee pain/injuries
Anemia Labyrinthitis
Angina Laceration
Ankle pain/injuries Lightheadedness
Anxiety States Lipoma
Arthritis - Unspecified Lumbar pain/Lumbar strain
Asthma/Wheeze Menopause
Atrial Fibrillation Menstrual Disorder
Attention Deficit Disorder / Hyperactivity Migraine
Bell's Palsy Mitral Valve Prolapse
Benign Prostatic Hypertrophy Mono
Bronchitis Musculoskeletal Pain - Other
Burn MVA
Cancer - Specific Type Myocardial Infarction (Heart Attack)
Cancer Screening Neck Sprain/Strain
Carpal Tunnel Syndrome Obesity
CAD/Chest Pain Onycomycosis
Cellulitis Osteoarthritis
Chest Pain/CAD Osteoporosis
Cholecystitis Otitis Media/Ear Pain
Chronic Obstructed Pulmonary Disease/Cough Parkinson's Disease
Cirrhosis Pelvic Inflammatory Disease
Congestive Heart Failure/Edema Peptic Ulcer Disease
Conjunctivitis/Red Eye/Eye Pain Pharyngitis
Constipation/Diarrhea/impaction Plantar Fasciitis
Contact Dermatitis and Other Eczema Pneumonia
Contraceptive visit Poison Ivy
Cough/Chronic Obstructed Pulmonary Disease Prenatal Visit/Pregnancy
Croup Pregnancy/Prenatal Visit
CVA/Stroke/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Delerium/Dementia Red Eye/Conjunctivitis/Eye Pain
Dementia/Delerium Rhinitis/Allergies
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diarrhea/constipation/impaction School Physical
Diverticulosis Seizures
Dyspepsia/GERD Shingles
Dysplastic Nevi Shoulder pain/injuries
Dyspnea Sinusitis
Ear Pain/Otitis Media Skin lesions
Edema/Congestive Heart Failure Skin Tags
Elbow pain/injuries Smoking/Tobacco
Elevated Blood Pressure Sports Physical
Erectile dysfunction Sprains/Strains - Other
Eye Pain/Conjunctivitis/Red Eye STD
Fatigue Stroke/CVA/Vertigo
Fever of unknown origin Substance Use/Abuse
Fracture - Specific Location Sunburn
Ganglion Cyst Syncope
Gastritis and Gastroduodenitis Tendonitis
Gastroenteritis and Colitis Tennis Elbow
General Medical Exam, well child exam, well adult exam, physicals Tinea Pedis
GERD/Dyspepsia Tobacco/Smoking
Gynecological Examination Tonsillitis
H. Pylori Unspecified Viral and Chlamydial Infections
Headache - Unspecified Upper Respiratory Infection
Health Examination of Defined Subpopulations Urinary Tract Infection
Heart Attack (Myocardial Infarction) Vaginal Candidiasis
Hemorrhoids Vaginitis
Hip pain/injuries Vaginosis
Hyperactivity/Attention Deficit Disorder Vertigo/Stroke/CVA
Hypercholesterolemia Warts
Hyperlipidemia - Other and Unspecified Wheeze/Asthma
Hypertension/Essential Wrist pain/injuries
Hyperthyroidism    
Hypothyroidism    
Immunization Other: 
Impaction/Constipation/Diarrhea    
Diagnosis 6:

(select only one)

(counts toward quota)

 

*None Infant or Child Health Check / Routine
Abdominal Pain Inflammatory Bowel Disease
Acne Influenza with Other Respiratory Manifestations
Alcoholism Ingrown Toenail
Allergies/Rhinitis Kidney Disease
Alzheimer's Disease Knee pain/injuries
Anemia Labyrinthitis
Angina Laceration
Ankle pain/injuries Lightheadedness
Anxiety States Lipoma
Arthritis - Unspecified Lumbar pain/Lumbar strain
Asthma/Wheeze Menopause
Atrial Fibrillation Menstrual Disorder
Attention Deficit Disorder / Hyperactivity Migraine
Bell's Palsy Mitral Valve Prolapse
Benign Prostatic Hypertrophy Mono
Bronchitis Musculoskeletal Pain - Other
Burn MVA
Cancer - Specific Type Myocardial Infarction (Heart Attack)
Cancer Screening Neck Sprain/Strain
Carpal Tunnel Syndrome Obesity
CAD/Chest Pain Onycomycosis
Cellulitis Osteoarthritis
Chest Pain/CAD Osteoporosis
Cholecystitis Otitis Media/Ear Pain
Chronic Obstructed Pulmonary Disease/Cough Parkinson's Disease
Cirrhosis Pelvic Inflammatory Disease
Congestive Heart Failure/Edema Peptic Ulcer Disease
Conjunctivitis/Red Eye/Eye Pain Pharyngitis
Constipation/Diarrhea/impaction Plantar Fasciitis
Contact Dermatitis and Other Eczema Pneumonia
Contraceptive visit Poison Ivy
Cough/Chronic Obstructed Pulmonary Disease Prenatal Visit/Pregnancy
Croup Pregnancy/Prenatal Visit
CVA/Stroke/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Delerium/Dementia Red Eye/Conjunctivitis/Eye Pain
Dementia/Delerium Rhinitis/Allergies
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diarrhea/constipation/impaction School Physical
Diverticulosis Seizures
Dyspepsia/GERD Shingles
Dysplastic Nevi Shoulder pain/injuries
Dyspnea Sinusitis
Ear Pain/Otitis Media Skin lesions
Edema/Congestive Heart Failure Skin Tags
Elbow pain/injuries Smoking/Tobacco
Elevated Blood Pressure Sports Physical
Erectile dysfunction Sprains/Strains - Other
Eye Pain/Conjunctivitis/Red Eye STD
Fatigue Stroke/CVA/Vertigo
Fever of unknown origin Substance Use/Abuse
Fracture - Specific Location Sunburn
Ganglion Cyst Syncope
Gastritis and Gastroduodenitis Tendonitis
Gastroenteritis and Colitis Tennis Elbow
General Medical Exam, well child exam, well adult exam, physicals Tinea Pedis
GERD/Dyspepsia Tobacco/Smoking
Gynecological Examination Tonsillitis
H. Pylori Unspecified Viral and Chlamydial Infections
Headache - Unspecified Upper Respiratory Infection
Health Examination of Defined Subpopulations Urinary Tract Infection
Heart Attack (Myocardial Infarction) Vaginal Candidiasis
Hemorrhoids Vaginitis
Hip pain/injuries Vaginosis
Hyperactivity/Attention Deficit Disorder Vertigo/Stroke/CVA
Hypercholesterolemia Warts
Hyperlipidemia - Other and Unspecified Wheeze/Asthma
Hypertension/Essential Wrist pain/injuries
Hyperthyroidism    
Hypothyroidism    
Immunization Other: 
Impaction/Constipation/Diarrhea    
Procedure:
(May select more than one)
*None ECG Pre-Natal Visit
Amniotomy EGD Remove Foreign Body
Anoscope Excision Sebaceous Cyst
Audiometry Eye Stain Skin Tag Removal
Biopsy Flex Sig Spirometry
Breast Exam H & P Stress Testing
Cast Hemocult Sutures
Cerumen Removal Immunization Throat Culture
Circumcision Incision & Drainage Toenail Removal
Colonoscopy Joint Injection Tympanometry
Cryo Procedure Nebulizer Treatment Ultrasound
C-Section Pap Smear Unna Boot
Delivery Peak Flow Urinalysis
Depo Shot Phlebotomy Vasectomy
Ear Washing Pregnancy Test *Other:

Notes/Comments: 

 

 Contact us: Harald Lausen, DO (Curriculum Information)
Jean Afflerbach (Web Master)

Page last updated Thursday August 15, 2013

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