Comprehensive SOAP Note Template
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COMPREHENSIVE SOAP NOTE TEMPLATE 2 Patent initials: J.M Age: 30 Gender: Male SUBJECTIVE DATA Chief Complaint (CC): The patient is a thirty years, old male white who came for a medical check-up af... ter experiencing abdominal pain and blood in the stool. The condition started a month ago. He also complained of recent severe rectal bleeding. History of the Present Illness (HPI): For several years, the patient had been receiving treatment for Crohn’s disease. He has been hospitalized two times for the same condition. Medications: Allergies: Urticaria Past Medical History (PMH): Delayed growth and development during his early age Past Surgical History (PSH): No surgical history Sexual/Reproductive History: Normal Personal/ Social History: Married for four years and have one son. Immunization History: No explicit information apart from immunization for tuberculosis and whooping cough Significant Family History: His father suffered from the same condition in his early twenties, his mother died of hypertension. Lifestyle: Does not smoke or drink Review of the System: He regularly experience appetite and weight loss. [Show More]
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