{note: trim=yes}Please enter the following information about the patient: Age (number of years): {formtext: name=Age} Sex: {formmenu: default=; female; male; name=sex} {endnote: trim=left}

• The patient is a {=Age} year old {=sex}.
• The patient's chart was reviewed and reconciled as noted in the HPI
• The patient's lifestyle was reviewed for possible impacts on health. I identified and addressed any barriers to improved health, such as age, gender, ethnic background, and, racial identity. Status of advanced health care planning was reviewed.
• The patient's self-reported or lab-reported vital signs were reviewed.
• Information was provided regarding healthy lifestyle choices and vaccinations.
• Based on recommendations for all or almost all adults, the patient was: Screened for depression, unhealthy alcohol use, smoking, and unhealthy drug use Screened for hypertension or recommended to screen for hypertension Offered screening for Hepatitis C and HIV Counseled regarding advanced care planning, including advanced directives, and offered follow up for future discussion if desired.

Specific concerns for this patient, if any: {formtoggle: name=BMI over 25; default=no; trim=right}- BMI between 25 and 30: The patient was offered screening for diabetes. The patient given information on healthy diet and exercise for prevention of diabetes.{endformtoggle: trim=left} {formtoggle: name=BMI over 30; default=no; trim=right}- BMI over 30: The patient was offered screening for diabetes. The patient was given information on healthy diet and exercise for weight loss and reduction of risk of diabetes and cardiac disease. {endformtoggle: trim=left} {formtoggle: name=Having more than 1 partner in 12 months; default=no; trim=right}{endformtoggle: trim=left} {formtoggle: name=Requesting testing for sexually transmitted infections; default=no; trim=right}{endformtoggle: trim=left} {formtoggle: name=Sexually active; default=no; trim=right}{endformtoggle: trim=yes}

{formtoggle: name=Unhealthy alcohol use; default=no; trim=right}- Unhealthy alcohol use: Depending on the patient's preference, the patient was encouraged to follow up with me, was referred to counseling, or was advised to seek an alcohol counseling/treatment program.{endformtoggle: trim=left} {formtoggle: name=Concern of depression or anxiety; default=no; trim=right}- Concern of depression or anxiety: Depending on the patient's preference, the patient was encouraged to follow up with me or was referred to counseling.{endformtoggle: trim=left} {formtoggle: name=Elevated blood pressure; default=no; trim=right}- Elevated blood pressure: the patient was encouraged to follow up with me.{endformtoggle: trim=left} {formtoggle: name=Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry; default=no; trim=right}{endformtoggle: trim=left}

Testing or screening ordered during this visit: {note: trim=right}{formmenu: Basic labs, including: CBC, CMP, Hemoglobin A1C, TSH, Lipids; Hepatitis B, Hepatitis C, HIV, Syphilis; Gonorrhea/chlamydia; Quantiferon Gold TB; Low dose CT screening for lung cancer; Ultrasound for AAA; BRCA testing; FIT, Cologard; Bone density scan; Mammogram; name=testing; multiple=yes}{endnote: trim=right} {if: testing=[]}None{else}{=join(testing,", ")}{endif}

Referrals placed during this visit: {note: trim=right}{formmenu: Behavioral Health; Gastroenterology for colonoscopy; OB/Gyn for women's health; name=referrals; multiple=yes}{endnote: trim=right} {if: referrals=[]}None{else}{=join(referrals,", ")}{endif}

The patient was advised to follow up at least annually for preventive health care, sooner as needed for review of results or discussion of concerns raised.

The patient verbalized a clear understanding of my instructions and was agreeable with the plan.