Hypertension Disorders

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of diagnosis.
2. Symptoms, if any.
2. Treatment - type, dosage, side effects.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Blood pressure - If the diagnosis of hypertension has not been previously established, readings must be taken two or more times on at least three different days. If hypertension has been previously diagnosed, take three blood pressure readings on the day of examination.
2. Cardiac status - size, function. If there is evidence of hypertensive heart disease, use Heart Worksheet.
3. If arteriosclerotic complications of hypertension are present, use worksheet for the specific condition(s) found.

D. Diagnostic and Clinical Tests:

1. X-rays or other tests, as indicated.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: