Preventive Health Evaluation (PHE) Note Template

Subjective:
Chief Complaint:
Follow-up for diabetes and hypertension management

ROS/Active Issues:
Head/Neck: No headaches, no vision changes, no hearing difficulties reported. Chest: No shortness of breath on exertion. Cardiovascular system: No chest pain on exertion, no palpitations. Gastrointestinal system: No changes in bowel movement frequency, no melena, no bright red blood per rectum. Genitourinary system: No bladder incontinence, no nocturia, no erectile dysfunction reported. Central nervous system: No paresthesias, no weakness. Musculoskeletal system: No joint pain. Skin: No concerning moles or patches. Mood: No mood disturbances reported. Sleep: No sleep disturbances reported. Other: No medication side effects. No known allergies.

Objective:
Preventive Health Evaluation:
Richard reports making efforts to improve his diet and increase physical activity by walking. No information provided regarding smoking status, alcohol consumption, illicit drug use, occupational risks, sexually transmitted infection history, contraception use, or sexual dysfunction.

Screening Blood work:
LDL cholesterol: Most recent value is 2.4 mmol/L. Screening recommended annually for patients with diabetes and cardiovascular risk factors. Hemoglobin A1c: Most recent value is 7.2%. Screening recommended every 3 months for diabetes management.

Preventive Screening Tests:
No preventive screening tests discussed or performed during this encounter.

Immunizations:
No immunization status or recommendations discussed during this encounter.

O/E:
Vital signs: Blood pressure is 138/84 mmHg. Weight is 84 kg. Body mass index is 28.3. SKIN  Normal.  LYMPH NODES  No lymphadenopathy present. HEENT    Pupils equal, round, reactive to light and accommodation; extraocular movements and visual fields normal; tympanic membranes clear. Pharynx clear, mucous membranes normal, no oral lesions, teeth normal, no thyroid masses or bruits. RESPIRATORY  Air entry equal bilaterally, no adventitious sounds, chest expansion normal. BREAST  No skin changes, no masses. CARDIOVASCULAR  S1 and S2 normal, jugular venous pressure normal, no murmurs, no pedal edema. ABDOMEN  Abdomen is soft, no tenderness, no organomegaly, no masses, no guarding or rebound, no costovertebral angle tenderness, no suprapubic tenderness, no hernias. No abdominal tenderness. PELVIC  Testicular exam not performed. NEUROLOGIC/MUSCULOSKELETAL  Mental status intact, cranial nerves 2-12 normal, strength, reflexes, sensation, gait, and range of motion normal. Foot sensation intact. No ankle swelling. No foot ulcers or skin issues.

Assessment and Plan:
Impression & Plan:
Type 2 diabetes and hypertension are being managed with metformin and ramipril, with no reported side effects. Richard is advised to continue dietary modifications focusing on high-fibre, low-glycemic foods, avoidance of sugary drinks, and reduction of sodium intake to approximately one teaspoon per day, including processed and restaurant foods. He is encouraged to continue regular walking and to add light strength training twice weekly if possible. Richard is instructed to keep a log of home blood glucose readings and bring it to the next visit. Referral to a dietitian is made for personalized dietary guidance. Laboratory tests will be repeated in three months. Return to clinic as scheduled.