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 Race:
African-American Mixed
Asian Native American
Caucasian Other
Hispanic    
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"
Chief Complaint:
(may select more than one)
Abdominal Pain Ingrown Toenail
Acne Knee/Shoulder Pain
Alcoholism Labyrinthitis
    Laceration
Allergies/Rhinitis Lightheadedness
Alzheimer's Disease Lipoma
Anemia Lumbar Strain/Sprain/Pain
Angina Menopause
Anxiety States Migraine
Arthritis - Unspecified Mitral Valve Prolapse
Asthma/Wheeze Mono
Atrial Fibrillation MVA
Attention Deficit Disorder / Hyperactivity Myocardial Infarction (Heart Attack)
Bell's Palsy Neck Sprain/Strain
Benign Prostatic Hypertrophy Obesity
Bronchitis Onycomycosis
Burn Osteoarthritis
Cancer - Specific Type Osteoporosis
Carpal Tunnel Syndrome Otitis Media
Cellulitis Parkinson's Disease
Chest Pain/CAD Pelvic Inflammatory Disease
Cholecystitis Peptic Ulcer Disease
Chronic Obstructed Pulmonary Disease/Cough Pharyngitis
Cirrhosis Plantar Fasciitis
Congestive Heart Failure/Edema Pneumonia
Contact Dermatitis and Other Eczema Poison Ivy
Croup Pregnancy
Stroke/CVA/Vertigo Pyelonephritis
Deep Vein Thromobosis Rash
Depressive Disorders Ringworm
Diabetes Mellitus Rosacea
Diverticulosis School Physical
Dysplastic Nevi Seizures
Elevated Blood Pressure Shingles
Fatigue Sinusitis
Fracture - Specific Location Skin Tags
Ganglion Cyst Sports Physical
Gastritis and Gastroduodenitis Sprains/Strains - Other
Gastroenteritis and Colitis STD
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 Abuse
Hemorrhoids Tonsillitis
Hypercholesterolemia Unspecified Viral and Chlamydial Infections
Hyperlipidemia - Other and Unspecified Upper Respiratory Infection
Hypertension / Essential Urinary Tract Infection
Hyperthyroidism Vaginal Candidiasis
Hypothyroidism Vaginitis
Imflammatory Bowel Disease Vaginosis
Infant or Child Health Check / Routine Warts
Influenza with Other Respiratory Manifestations Other:
Diagnosis 1:

(select only one)

(counts toward quota)

 
Abdominal Pain Ingrown Toenail
Acne Knee/Shoulder Pain
Alcoholism Labyrinthitis
    Laceration
Allergies/Rhinitis Lightheadedness
Alzheimer's Disease Lipoma
Anemia Lumbar Strain/Sprain/Pain
Angina 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 Otitis Media
Cellulitis Parkinson's Disease
Chest Pain/CAD Pelvic Inflammatory Disease
Cholecystitis Peptic Ulcer Disease
Chronic Obstructed Pulmonary Disease/Cough Pharyngitis
Cirrhosis Plantar Fasciitis
Congestive Heart Failure/Edema Pneumonia
Contact Dermatitis and Other Eczema Poison Ivy
Contraceptive visit Pregnancy/Prenatal Visit
Croup Pyelonephritis
Stroke/CVA/Vertigo Rash
Deep Vein Thromobosis Ringworm
Dementia/Delerium Rosacea
Depressive Disorders School Physical
Diabetes Mellitus Seizures
Diverticulosis Shingles
Dysplastic Nevi Shoulder/ankle pain
Dyspnea Sinusitis
Elevated Blood Pressure Skin lesions
Erectile dysfunction Skin Tags
Fatigue Sports Physical
Fracture - Specific Location Sprains/Strains - Other
Ganglion Cyst STD
    Substance Use/Abuse
Gastritis and Gastroduodenitis Sunburn
Gastroenteritis and Colitis Syncope
General Medical Exam, well child exam,
well adult exam, physicals		 Tendonitis
GERD/Dyspepsia Tennis Elbow
Gynecological Examination Tinea Pedis
H. Pylori Tobacco/Smoking
Headache - Unspecified Tonsillitis
Health Examination of Defined Subpopulations Unspecified Viral and Chlamydial Infections
Hemorrhoids Upper Respiratory Infection
Hypercholesterolemia Urinary Tract Infection
Hyperlipidemia - Other and Unspecified Vaginal Candidiasis
Hypertension / Essential Vaginitis
Hyperthyroidism Vaginosis
Hypothyroidism Warts
Imflammatory Bowel Disease    
Immunization    
Infant or Child Health Check / Routine Other: 
Influenza with Other Respiratory Manifestations  
Diagnosis 2:

(select only one)

(counts toward quota)

 
None  
Abdominal Pain Ingrown Toenail
Acne Knee/Shoulder Pain
Alcoholism Labyrinthitis
    Laceration
Allergies/Rhinitis Lightheadedness
Alzheimer's Disease Lipoma
Anemia Lumbar Strain/Sprain/Pain
Angina 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 Otitis Media
Cellulitis Parkinson's Disease
Chest Pain/CAD Pelvic Inflammatory Disease
Cholecystitis Peptic Ulcer Disease
Chronic Obstructed Pulmonary Disease/Cough Pharyngitis
Cirrhosis Plantar Fasciitis
Congestive Heart Failure/Edema Pneumonia
Contact Dermatitis and Other Eczema Poison Ivy
Contraceptive visit Pregnancy/Prenatal Visit
Croup Pyelonephritis
Stroke/CVA/Vertigo Rash
Deep Vein Thromobosis Ringworm
Dementia/Delerium Rosacea
Depressive Disorders School Physical
Diabetes Mellitus Seizures
Diverticulosis Shingles
Dysplastic Nevi Shoulder/ankle pain
Dyspnea Sinusitis
Elevated Blood Pressure Skin lesions
Erectile dysfunction Skin Tags
Fatigue Sports Physical
Fracture - Specific Location Sprains/Strains - Other
Ganglion Cyst STD
    Substance Use/Abuse
Gastritis and Gastroduodenitis Sunburn
Gastroenteritis and Colitis Syncope
General Medical Exam, well child exam,
well adult exam, physicals		 Tendonitis
GERD/Dyspepsia Tennis Elbow
Gynecological Examination Tinea Pedis
H. Pylori Tobacco / Smoking
Headache - Unspecified Tonsillitis
Health Examination of Defined Subpopulations Unspecified Viral and Chlamydial Infections
Hemorrhoids Upper Respiratory Infection
Hypercholesterolemia Urinary Tract Infection
Hyperlipidemia - Other and Unspecified Vaginal Candidiasis
Hypertension / Essential Vaginitis
Hyperthyroidism Vaginosis
Hypothyroidism Warts
Imflammatory Bowel Disease    
Immunization    
Infant or Child Health Check / Routine Other: 
Influenza with Other Respiratory Manifestations  
Diagnosis 3:

(select only one)

(counts toward quota)

 
None  
Abdominal Pain Ingrown Toenail
Acne Knee/Shoulder Pain
Alcoholism Labyrinthitis
    Laceration
Allergies/Rhinitis Lightheadedness
Alzheimer's Disease Lipoma
Anemia Lumbar Strain/Sprain/Pain
Angina 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 Otitis Media
Cellulitis Parkinson's Disease
Chest Pain/CAD Pelvic Inflammatory Disease
Cholecystitis Peptic Ulcer Disease
Chronic Obstructed Pulmonary Disease/Cough Pharyngitis
Cirrhosis Plantar Fasciitis
Congestive Heart Failure/Edema Pneumonia
Contact Dermatitis and Other Eczema Poison Ivy
Contraceptive visit Pregnancy/prenatal visit
Croup Pyelonephritis
    Rash
Deep Vein Thrmobosis Ringworm
Dementia/Delerium Rosacea
Depressive Disorders School Physical
Diabetes Mellitus Seizures
Diverticulosis Shingles
Dysplastic Nevi Shoulder/ankle pain
Dyspnea Sinusitis
Elevated Blood Pressure Skin lesions
Erectile dysfunction Skin Tags
Fatigue Sports Physical
Fracture - Specific Location Sprains/Strains - Other
Ganglion Cyst STD
    Stroke/CVA/Vertigo
    Substance Use/Abuse
Gastritis and Gastroduodenitis Sunburn
Gastroenteritis and Colitis Syncope
General Medical Exam Tendonitis
GERD/Dyspepsia Tennis Elbow
Gynecological Examination Tinea Pedis
H. Pylori Tobacco/Smoking
Headache - Unspecified Tonsillitis
Health Examination of Defined Subpopulations Unspecified Viral and Chlamydial Infections
Hemorrhoids Upper Respiratory Infection
Hypercholesterolemia Urinary Tract Infection
Hyperlipidemia - Other and Unspecified Vaginal Candidiasis
Hypertension / Essential Vaginitis
Hyperthyroidism Vaginosis
Hypothyroidism Warts
Imflammatory Bowel Disease    
Immunization    
Infant or Child Health Check / Routine Other: 
Influenza with Other Respiratory Manifestations  

Type of Visit: 
Diagnostic Admission
Therapeutic Consult/Referral
Follow-Up Family/Psychosocial
Patient Education    
Procedure:
(May select more than one)
*None Immunization
Amniotomy Incision & Drainage
Anoscope Joint Injection
Audiometry Nebulizer Treatment
Biopsy Pap Smear
Breast Exam Peak Flow
Cast Phlebotomy
Cerumen Removal Pregnancy Test
Circumcision Pre-Natal Visit
Colonoscopy Remove Foreign Body
Cryo Procedure Sebaceous Cyst
C-Section Skin Tag Removal
Delivery Spirometry
Depo Shot Stress Testing
Ear Washing Sutures
ECG Throat Culture
EGD Toenail Removal
Excision Tympanometry
Eye Stain Ultrasound
Flex Sig Unna Boot
H & P Urinalysis
Hemocult Vasectomy
  *Other:
Procedure Role: Observed
 Assisted
 Performed

Continuity:

Community Agency:

History/Physical Exam:

Complete Writeup Brief Workup Observed Only

Notes/Comments: 

 

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

Page last updated Friday November 06, 2009

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