Evaluation & Management Form

Location Name : 8150 Southwest Freeway, Houston TX 77074
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Drug Allergies & Special Considerations :

List of Drugs & Other Products Tried :

Constitutional-General Appearance:

Build, Nutrition, Posture, Grooming (Normal?)

Vital Signs Wt. Pulse, BP, Temp (Normal?)


Alert & Oriented in T/S/P (Normal?)

Mood and Affect (Normal?)

Hair & Seat Glands:

Scalp & Body Hair (Normal?)

Eccrine & Apocrine Glands (Normal?)

Ear, Nose, Mouth & Throat:

Lips, Teeth and Gums (Normal?)

Oropharynx (Normal?)


No anal growths or fissures (Normal?)

No hepatosplenomegally (Normal?)

Skin & Subcutaneous Tissues are Normal:

Head & Face:


Chest, Breast & Axillae:


Genitalia. Groin & Buttocks:

Right Upper Extremity:

Left Upper Extremity:

Right Lower Extremity:

Left Lower Extremity:

Eyes: Eyelids and Conjunctivae (Normal?)

Neck: Thyroid, nodules or masses (Normal?)

Cardiovascular(Peripheral): No edema, Circulation ok (Normal?)

Extremities: No digital cyanosis or clubbing (Normal?)

Lymph Nodes: 1-Neck 2-Axillae 3-Groin (Normal?)

Clinical History & Diagnostic Studies reviewed:

Clinical Impression

Follow Up :

Management Plan

Follow Up :

Chaperone & Scribe


Pertinent Details (Photo &/or Audiovisual documentation) :