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SOAP Note Template

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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 Weakness Fever/Chills Weight Gain Weight Loss Trouble Sleeping Night Sweats Other: Itching Rashes Nail Changes Skin Color Changes Other: Diplopia Eye Pain Eye redness Vision changes Photophobia Eye discharge Earache Tinnitus Epistaxis Vertigo Hearing Changes Hoarseness Oral Ulcers Sore Throat Congestion Rhinorrhea Other: Respiratory Neuro Cardiovascular Cough Hemoptysis Dyspnea Wheezing Pain on Inspiration Sputum Production Other: Syncope or Lightheadedness Headache Numbness Tingling Sensation Changes Speech Deficits Other: Chest pain SOB Exercise Intolerance Orthopnea Edema Murmurs Palpitations Faintness OC Changes Claudications PND Other: MSK GI GU PSYCH Pain Stiffness Crepitus Swelling Limited ROM Redness Misalignment Other: Nausea/Vomiting Dysphasia Diarrhea Appetite Change Heartburn Blood in Stool Abdominal Pain Excessive Flatus Food Intolerance Rectal Bleeding Other: Urgency Dysuria Burning Hematuria Polyuria Nocturia Incontinence Other: Stress Anxiety Depression Suicidal/Homicidal Ideation Memory Deficits Mood Changes Trouble Concentrating Other: GYN Rash Discharge Itching Irregular Menses Dysmenorrhea Foul Odor Amenorrhea LMP: Contraception Other: Body System Positive Findings Negative Findings General Skin HEENT Respiratory Neuro Cardiovascular Musculoskeletal Gastrointestinal Genitourinary Psychiatric Gynecological Problem List 6 11 2 7 12 3 8 13 [Show More]

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