NSN 7540-00-634-4176

600-108

HEALTH RECORD
DATE

CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

Opening Statement ID: Age

Marital status Race Gender Duty status Rank Unit TIS TIU TI Theater

REFERRAL:

Self

CDR

Clinic _

Chaplain

Other

CC: Pt reported the following:

HPI: (Onset, duration, frequency, Impairment, effects)

Sleep:

(Not affected / Initial / Middle / Terminal) (Not affected / Decreased / Increased)

Interest: Guilt:

(None / Guilt / Worthlessness / Other) (Not affected / Decreased / Increased) (Not affected / Impaired)

Energy:

Concentration: Appetite:

(No change / Increased / Decreased) (Wt same / up / down) (Normal / Accelerated / Slowed)

Psychomotor: SI/HI/PEI:

(Denied all / SI / HI / PEI)

Stressors:

Current Medical: (Trauma, illnesses, conditions being treated for)

Allergies: (NKDA / Other) Nicotine: (Denied use / Other)

OTC or Pres Meds: (Denied / Other) ETOH: (Denied / Other)

Illicits/supplements: (Denied / Other) Psych HX: (In/outpatient, rehab, dx, meds, self-harm)

PATIENTS IDENTIFICATION (Use this space for Mechanical Imprint)

RECORDS MAINTAINED AT:

PATIENTS NAME (Last, First, Middle Initial) RELATIONSHIP TO SPONSOR SPONSORS NAME DEPART./SERVICE SSN/IDENTIFICATION NO. STATUS SEX RANK/GRADE ORGANIZATION DATE OF BIRTH

CHRONOLOGICAL RECORD OF MEDICAL CARE

STANDARD FORM 600 (REV. 5-84) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505

DATE

Cont. Family psych Hx: (Denied all

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

/ In/outpatient / Rehab / dx / Meds / Self-harm)

Family Hx: (raised by, setting, siblings, typical problems, abuse, significant events)

Developmental Hx: (childhood problems / Learning / Fitting in / Emotional / Acting out / Violence / Self-harm / Criminal /
Destructive / Med/health / ADHD / Authority / Drugs / ETOH / Other behavioral)

Education Hx: (highest level, typical problems, goals, spec ed, significant events)

Occup/Military: (equal to ability, performance, discipline, awards, promotion, interaction, typical problems, significant events)

Social Hx: (living arrangements, family structure, socio economic, relationships family & others, typical problems, significant events)

Personal Hx: (typical activities, financial, legal, Drug/ETOH, gambling, habits, typical problems, significant events)

Other significant history:

*U.S. Government Printing Office: 1991 312-071/40213

STANDARD FORM 600 BACK (REV. 5-84)