SOAP NOTE SPORTS PHYSICAL Name: JM Date: 09/18/16 Time: 10:25 Age: 14 Sex: Female SUBJECTIVE CC: Mother states “She is here today for a sports physical for basketball” HPI: JM is a white non-Hispanic patient here today for her well child check-up. She is currently a Sophomore at School. JM appears healthy in non-acute distress, requesting sports physical evaluation for school. JM does well in school and belongs to high honor roll and plays basketball during winter and track during spring. Medications: MVI 1 tablet PO daily PMH Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas No past medical history, no surgeries, normal developmental millstones. No psychiatric history. No sexually active. All vaccines up to date. Last influenza vaccine was 09/01/16. Hospitalizations/Surgeries None Family History The patient lives at home with her mother and father she has a twin brother and they have no pets. All 4 grandparents are alive and without disease. Social History Patient and her family currently live in a condo in Sussex county NJ her parents and brother. She has never used alcohol, tobacco, or any illicit drugs. Denies anxiety or depression and is generally happy.
ROS General Patient denies weight change, fatigue, fever, chills, night sweats, and energy level. Denies
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- Fall '17
- Ear canal, Rash, denies, white non-Hispanic patient, normal developmental millstones