SKIN EXAMINATION FORM

ACCT#: 262594M

Name: History Form of ____/____/____ Reviewed. Date _____/_____/_____

Medications: New Allergies:

CC and HPI Pertinent Info:

[ ] Vitals: (3) BP: Sitting R___/___L___/___ Supine R___/___L___/___

Diabetic [ ] Hypertensive [ ] R _________________T________________Wt_____________Ht___________

Examination Detail Pertinent Positives and NegativesGENERAL: □ Well Developed, well nourished, no acute distress. EYES: □ EOM Intact, equal in size and movement.ENT: □ Lips and symmetrical, good dentition, gums pink. □ Oral mucosa pink and moist. Soft and hard palates contiguous. Tongue moist, without ulcers. Gag reflex present.NECK: □ No tenderness, masses or thyromegaly.CARD: □ No peripheral edema, no varicosities. Skin warm and dry.ABDOMEN: □ Liver and spleen without tenderness or enlargement.□ No anal lesions.LYMPH: □ No tenderness or enlargement.□ Neck □ Axillary □ Groin □ Other _________ EXTREMITIES: □ No deformity, clubbing or cyanosis.SKIN: □ Hair distribution normal.

No rashes, lesions or ulcers in the following areas:

(4 of the following 5 areas)

□ 1-Head & Neck

□ 2-Chest/breasts/back

□ 3-Abdomen

□ 4-Genitalia

□ 5-ExtremitiesSKIN: □ No profuseness or discoloration of sweat, no foul odor noted.NEURO/PSYCH: □ Alert and oriented X3 □ No mood disorders noted, calm effect.

Assessment: Plan:

Data Reviewed F / U:

Signature:

Color Code-It™ © 1997 HCCA, Inc. Prob. Focused = 1 √ Exp. Prob, Focused = 6 √ Detailed = 12 √ Comprehensive = All √’s in Red-Bar areas & 1 √ in all other areas

Only those elements determined to be medically necessary should be counted.