S: Subjective
Information the patient or patient representative told you
SOAP Note Template
Initials: TJ Age: 28 years old Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170cm 88 kg 139/8 82 16 98.9 99% 3/10 Medication: Penicillin (causes rash and hives)
7 Food:None
Environment: Cats, dust (cause asthma exacerbation)
History of Present Illness (HPI)
Chief Complaint (CC) Headaches with neck pain CC is a BRIEF statement identifying
why the patient is here - in the patient’s
Onset 1 week ago after car accident, symptoms because 2 days after accident. own words - for instance "headache",
Location Headache at the crown and back of the head NOT "bad headache for 3 days”.
Sometimes a patient has more than
Duration Lasts 1-2 hours daily one complaint. For example: If the pa-
tient presents with cough and sore
Characteristics Dull pain while experiencing headache throat, identify which is the CC and
Aggravating Factors Pain when moving her neck which may be an associated symptom
Relieving Factors Rest and Tylenol as needed
Treatment (PRN) As needed two regular strength Tylenol
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Proventil Inhaler 90 mcg 2 puffs as needed Every 4 hours as Wheezing
, needed Shortness of breath
Tylenol 650 mg (states she Once a day The past few Headaches
takes two tablets) days
Advil 200 mg TID PRN First couple of Cramping
days of men-
strual cycle
Flovent inhaler Click or tap here to en- Click or tap here to enter Click or tap here Asthma
ter text. text. to enter text.
Click or tap here to enter text. Click or tap here to en- Click or tap here to enter Click or tap here Click or tap here to enter text.
ter text. text. to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospi-
talizations, and surgeries. Depending on the CC, more info may be needed.
Tina was diagnosed with Diabetes Mellitus type 2 at the age of 24 years old. She is non-compliant with taking her metformin, as well as checking
blood sugar on a regular basis.
Diagnosed with asthma at the age of 2 and a half. Has been taking her inhaler as needed for asthma exacerbation; currently it is not being as effec-
tive as it was. Is now on Flovent which has been providing relief for maintenance.
Suffers from heavy periods that include cramping as well as tenderness. Tina has irregular periods which last between 9-10 days.
Immunizations are current, has received vaccinations for childhood.
Flu shot received last 5 to 6 years ago.
Last tetanus shot was about two years ago.
Last pap smear was done about 4 years ago, and was normal. Tina has Polycystic ovarian syndrome.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Patient denies smoking, denies recreational drug use. Patient is a former pot smoker who quit when she was 20 or 21 years old. She is occasionally
exposed to second hand smoke socially as her friends smoke. Drinks alcohol occasionally, about 6 drinks a month. Patient is currently a student
working on obtaining her bachelors degree in accounting. Patient lives with her mother and sister who support her dreams. Patient became sexually
active at the age of 18 and has had 3 male sexual partners in total. Denies using birth control at the moment.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if perti-
, nent.
Mother history of HTN and high cholesterol.
Father history of HTN, diabetes mellitus type 2, high cholesterol ( Passed away in car accident).
Paternal grandmother history of HTN and high cholesterol.
Paternal grandfather history of HTN, diabetes, colon cancer (passed away from colon cancer).
Brother is obese.
Sister has asthma.
Maternal grandmother history of hypertension, and high cholesterol (deceased from stroke at 73 years old)
Maternal grandfather HTN, high cholesterol.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue Click or tap here ☐Itching Click or tap ☐Diplopia Click or tap ☐Earache Click or tap here ☐Hoarseness Click or tap here
to enter text. here to enter text. here to enter text. to enter text. to enter text.
☐Weakness Click or tap ☐Rashes Click or tap ☐Eye Pain Click or tap ☐Tinnitus Click or tap here ☐Oral Ulcers Click or tap here
here to enter text. here to enter text. here to enter text. to enter text. to enter text.
☐Fever/Chills Click or tap ☐Nail Changes Click or ☐Eye redness Click or tap ☐Epistaxis Click or tap ☐Sore Throat Click or tap here
here to enter text. tap here to enter text. here to enter text. here to enter text. to enter text.
☐Weight Gain Click or tap ☐Skin Color Changes ☐XVision changes Click ☐Vertigo Click or tap here ☐Congestion Click or tap here
here to enter text. Click or tap here to en- or tap here to enter text. to enter text. to enter text.
☐Weight Loss Click or tap ter text. ☐Photophobia Click or tap ☐Hearing Changes Click or ☐Rhinorrhea Click or tap here
here to enter text. ☐Other: here to enter text. tap here to enter text. to enter text.
☐Trouble Sleeping Click or Click or tap here to en- ☐Eye discharge Click or ☐Other:
tap here to enter text. ter text. tap here to enter text. Click or tap here to enter text.
☐Night Sweats Click or tap
here to enter text.
☐Other:
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