Student Name: 


Elective:  If Extramural or IDE, enter course number and name here:

Elective End Week: 

Date Patient Seen: 

Patient's Age:
Newborn (0-11 mo)
Pediatrics (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)
Geriatric (65+ years)
Patient's Gender:
Type of Problem:
Health Maintenance 


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




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

Page last updated Tuesday February 14, 2017