Samples of clinic notes can be found on the www.medicineclinic.org/charting.html

Patient Name:                                    MRN:                               Primary Language:

Home Phone:                                     Mailing Address:

Proxy (or emergency contact):

Health Maintenance Schedule

Vaccines(date):     Td:                  Pneumovax:                HepB:             

                            Flu:                        

*Did you provide counseling on: exercise/diet, cigarette/ETOH/substance use, safety, psychosocial issues, safe sex/STD

Problem List                                                    Medication List: