Family Medicine Template

Concise SOAP template (Clone)

A professional Family Medicine template for healthcare professionals.

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Subjective:
F/u DM, HTN
Trying to control sugars, BP
Diet, ↑activity
No known drug allergies
No SE from metformin, ramipril
Brother dx DM

Chief Complaint:
Follow-up for diabetes and hypertension management

Objective:
BP 138/84
Wt 84kg
BMI 28.3
FPG 7.8 mmol/L
HbA1c 7.2%
LDL 2.4 mmol/L
TG 1.8
Heart/lungs nl
No ankle swelling
Abd soft, no tenderness
Foot sensation intact
No foot ulcers/skin issues

Assessment and Plan:
1. Type 2 DM (E11.9):
• Continue metformin
• Dietitian referral
• Monitor home BG, log
• Repeat labs 3mo
2. HTN (I10):
• Continue ramipril
• Salt restriction advice
• Encourage exercise
3. Dyslipidemia (E78.5):
• Monitor lipids
• Diet advice

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This comprehensive new patient template helps establish care by capturing complete medical history, current concerns, and baseline health status. Use this for patients during their initial visit to create a thorough medical record.

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