SOAP Note Form CP1 for soaps #1 and #2
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
J.S., 28 y/o female, reliable historian Mother – HTN; Father – Type 2 DM
Personal/Social Hx:
Chief Concern/RFE: Works as an elementary school
Burning when peeing and frequent urination for the past two days teacher; drinks socially drinks/week;
sexually active with one partner; uses
condoms regularly
Hx Present Illness: (write in paragraph format)
J.S. is a 28-year-old female presenting with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She
denies fever, flank pain, or vaginal discharge. No recent travel, new sexual partners, or changes in hygiene. She reports
similar symptoms approximately one year ago, which resolved with antibiotics. She has been increasing her fluid intake,
which has slightly helped with symptoms.
CURRENT HEALTH
Medications: Ibuprofen 200 mg 1 tab every 4-6 hours PRN for menstrual cramps and Daily multivitamin
Allergies: No Known Drug Allergies
Last PE & Screenings: Annual exam 6 months ago – normal
Immunization Status: Up to date, including influenza and Tdap
LMP & Birth Control (if applicable) LMP 2 weeks ago; uses condoms
PMH
Illnesses & Trauma: History of UTI x1 in past year
Hospitalizations/Surgeries: Denies any hospitalizations or surgeries
OB Hx/Sexual Hx: Sexually active, denies history of STIs
Emotional/Psy Hx: No history of depression or anxiety
REVIEW OF SYSTEMS
General Denies fever, body malaise, night sweats, excessive sweating, sudden weight change, reports mild fatigue
Nutrition Denies dietary restrictions, denies loss of appetite, intake: protein more than carbs, stays away from sweets, caffeine intake 3 cups
of coffee/day
Skin/Hair/Nails Denies rashes, open wounds, itchiness, hair loss, no ridges or brittling of nails, no missing nails
HEENT Denies frequent unusual headaches, migraines dizziness, eye pain, redness in eyes, issues with visual acuity, changes to vision
that was abrupt, denies ear pain, drainage, redness, tinnitus, foreign body, feeling of fullness, denies difficulty swallowing, denies wearing
contacts or glasses, denies runny nose or congestion, sinus pain, post nasal drainage, last dental exam was 01/2025
Breasts Denies masses or pain
Respiratory No respiratory symptoms reported
CV/peripheral vascular No chest pain, palpitations, edema reported
GI No nausea, vomiting, or abdominal pain reported
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
J.S., 28 y/o female, reliable historian Mother – HTN; Father – Type 2 DM
Personal/Social Hx:
Chief Concern/RFE: Works as an elementary school
Burning when peeing and frequent urination for the past two days teacher; drinks socially drinks/week;
sexually active with one partner; uses
condoms regularly
Hx Present Illness: (write in paragraph format)
J.S. is a 28-year-old female presenting with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She
denies fever, flank pain, or vaginal discharge. No recent travel, new sexual partners, or changes in hygiene. She reports
similar symptoms approximately one year ago, which resolved with antibiotics. She has been increasing her fluid intake,
which has slightly helped with symptoms.
CURRENT HEALTH
Medications: Ibuprofen 200 mg 1 tab every 4-6 hours PRN for menstrual cramps and Daily multivitamin
Allergies: No Known Drug Allergies
Last PE & Screenings: Annual exam 6 months ago – normal
Immunization Status: Up to date, including influenza and Tdap
LMP & Birth Control (if applicable) LMP 2 weeks ago; uses condoms
PMH
Illnesses & Trauma: History of UTI x1 in past year
Hospitalizations/Surgeries: Denies any hospitalizations or surgeries
OB Hx/Sexual Hx: Sexually active, denies history of STIs
Emotional/Psy Hx: No history of depression or anxiety
REVIEW OF SYSTEMS
General Denies fever, body malaise, night sweats, excessive sweating, sudden weight change, reports mild fatigue
Nutrition Denies dietary restrictions, denies loss of appetite, intake: protein more than carbs, stays away from sweets, caffeine intake 3 cups
of coffee/day
Skin/Hair/Nails Denies rashes, open wounds, itchiness, hair loss, no ridges or brittling of nails, no missing nails
HEENT Denies frequent unusual headaches, migraines dizziness, eye pain, redness in eyes, issues with visual acuity, changes to vision
that was abrupt, denies ear pain, drainage, redness, tinnitus, foreign body, feeling of fullness, denies difficulty swallowing, denies wearing
contacts or glasses, denies runny nose or congestion, sinus pain, post nasal drainage, last dental exam was 01/2025
Breasts Denies masses or pain
Respiratory No respiratory symptoms reported
CV/peripheral vascular No chest pain, palpitations, edema reported
GI No nausea, vomiting, or abdominal pain reported
