SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Past Medical History

ajor/Chronic Illnesses____________________________________________________
rauma/Injury ___________________________________________________________
ospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: ____________________________________________________________
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Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
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GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
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GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
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2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
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Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
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VJ 2018
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VJ 2018

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