YEAR-OLD FEMALE WITH INTENSE
HEADACHES – COMPLETE CLINICAL
ASSESSMENT AND MANAGEMENT PLAN
, 1. Patient Information
Name Not disclosed in case (Confidential)
Age 26 years
Gender Female
Height (If provided, include here)
Weight (If provided, include here)
BMI (If calculable, include here)
Occupation (Insert if provided, e.g., student, employed)
Ethnicity Not specified
2. Reason for Encounter
“I’ve been having these really bad
Chief Concern
headaches more often.”
Duration of
Worsening over the past month
Problem
Outpatient clinic visit due to headache
Context
affecting daily function