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

(select only one)

(counts toward quota)

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

(select only one)

(counts toward quota)

 
None Ingrown Toenail
Abdominal Pain Kidney Disease
Acne Knee pain/injuries
Alcoholism Labyrinthitis
Allergies/Rhinitis Laceration
Alzheimer's Disease Lightheadedness
Anemia Lipoma
Angina Lumbar Strain/Sprain/Pain
Ankle pain/injuries Menopause
Anxiety States Menstrual Disorder
Arthritis - Unspecified Migraine
Asthma/Wheeze Mitral Valve Prolapse
Atrial Fibrillation Mono
Attention Deficit Disorder / Hyperactivity MVA
Bell's Palsy Myocardial Infarction (Heart Attack)
Benign Prostatic Hypertrophy Neck Sprain/Strain
Bronchitis Obesity
Burn Onycomycosis
Cancer - Specific Type Osteoarthritis
Cancer Screening Osteoporosis
Carpal Tunnel Syndrome Other Musculoskeletal Pain
Cellulitis Otitis Media/Ear Pain
Chest Pain/CAD Parkinson's Disease
Cholecystitis Pelvic Inflammatory Disease
Chronic Obstructed Pulmonary Disease/Cough Peptic Ulcer Disease
Cirrhosis Pharyngitis
Congestive Heart Failure/Edema Plantar Fasciitis
Conjunctivitis/Red Eye/Eye Pain Pneumonia
Contact Dermatitis and Other Eczema Poison Ivy
Contraceptive visit Pregnancy/prenatal visit
Croup Pyelonephritis
Deep Vein Thrmobosis Rash
Dementia/Delerium Ringworm
Depressive Disorders Rosacea
Diabetes Mellitus School Physical
Diarrhea/constipation/impaction Seizures
Diverticulosis Shingles
Dysplastic Nevi Shoulder/hip/knee/ankle pain
Dyspnea Sinusitis
Elbow pain/injuries Skin lesions
Elevated Blood Pressure Skin Tags
Erectile dysfunction Sports Physical
Fatigue Sprains/Strains - Other
Fracture - Specific Location STD
Ganglion Cyst Stroke/CVA/Vertigo
Gastritis and Gastroduodenitis Substance Use/Abuse
Gastroenteritis and Colitis Sunburn
General Medical Exam, well child exam, well adult exam, physicals Syncope
GERD/Dyspepsia Tendonitis
Gynecological Examination Tennis Elbow
H. Pylori Tinea Pedis
Headache - Unspecified Tobacco/Smoking
Health Examination of Defined Subpopulations Tonsillitis
Hemorrhoids Unspecified Viral and Chlamydial Infections
Hip pain/injuries Upper Respiratory Infection
Hypercholesterolemia Urinary Tract Infection
Hyperlipidemia - Other and Unspecified Vaginal Candidiasis
Hypertension / Essential Vaginitis
Hyperthyroidism Vaginosis
Hypothyroidism Warts
Imflammatory Bowel Disease Wrist pain/injuries
Immunization Other: 
Infant or Child Health Check / Routine    
Influenza with Other Respiratory Manifestations    
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 Wednesday July 25, 2012

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