{Patient Name} {Medical Record Number} {Today's date and time}



Physical exam:

HEENT:

Scalp: ***

Ears: ***

Nose: ***

Mouth: ***

Neck: ***

Midline tenderness: {YES/NO:10027}

Abdomen: ***

Back: ***

Pelvis and Perineum: ***

Extremities: 

Upper: ***

Lower:  ***

Pulses:  ***

Neuro:  ***

Motor:  ***

Sensory:

Other: ***

CT Scans (note all results must be confirmed by faculty or printed report)

{CT SCANS:11677}



Xrays:

{XRAYS:11678}



Special Studies:

{SPECIAL STUDIES:11679}



Primary encounter diagnosis: ***



Patient Active Problem List

Diagnoses	Date Noted

{Active Problem List with Date}





Consults: ***



Tertiary Survey complete (mental status adequate for full examination): {YES/NO:10027}



C-spine cleared (radiologically and clinically):  {YES/NO:10027}



Examiner: {Physician Name}

Co-sign staff: ***