HISTORY AND PHYSICAL EXAMINATION

Date of Interview: ___________________________________

Time of History: _____________________________________

Informant: _________________________________________

Relationship to the Patient: ___________________________

% Reliability: _______________________________________

GENERAL DATA

Patient’s Name: _____________________________________

Age: ____ Sex: ____ Marital Status: _____________________

Address: ___________________________________________

Birthday: _____________ Birthplace: ____________

Nationality: ______________ Religion: ______________

Occupation: ________________________________________

Date of Admission: __________________________________

Time of Admission: __________________________________

No. of times admitted at OMMC: _______________________

CHIEF COMPLAINT

__________________________________________________

HISTORY OF PRESENT ILLNESS

Onset: ____________________________________________

Duration: _________________________________________

Frequency: _________________________________________

Setting at which the Symptom Occurred:

__________________________________________________

__________________________________________________

Manifestations:

Location: __________________________________________

Precipitating Factors: ________________________________

Quality: ___________________________________________

Radiation: _________________________________________

Severity: ___________________________________________

Aggravating Factors: _________________________________

Alleviating Factors: __________________________________

Previous Treatment for the Problem: ____________________

Associated Signs and Symptoms: _______________________

__________________________________________________

Pertinent Positives and Negatives: _____________________

__________________________________________________

Additional Notes: ___________________________________

__________________________________________________

__________________________________________________

PAST MEDICAL HISTORY

Current Medications:Generic Brand Dosage Frequency Purpose

Immunizations:

BCG DPT Polio Hepa B Measles

Others: ____________________________________________

Allergies:

Food: ______________________________________

Medications: ________________________________

Pollen/Animals/Others: _______________________

Childhood Illness:

Rheumatic Fever Polio

Chicken Pox Measles

Mumps

Others: ____________________________________

Adult Illness:Illness Age Date of Diagnosis

HPN

Stroke

Renal

Asthma

TB

DM

Cardiac

GI

STD

Others

Surgical Procedures:

Date: _____________________________________________

Type of Operation: __________________________________

Purpose: __________________________________________

Previous Hospitalizations:Date Cause Hospital Treatment

Screening Tests:Test Date Result

Tuberculin Test

Pap Smear

Mammogram

Occult blood in stool

Cholesterol test

Urinalysis

X-ray/CT Scan/MRI

Others

MENSTRUAL AND OBSTETRIC HISTORY

LMP: ________________ PMP: ________________

Age of menarche: ____________ Period: Regular/Irregular

Character of flow: ___________________________________

Duration of period (range): ____________________________

No. of pads used per day: _____________________________

PMS: _____________________________________________

Age of Menopause: _________

Age of 1st coitus: _____ No. of sexual partners: _____

History of post-coital bleeding, pelvic infection, dyspareunia:

__________________________________________________

Birth control methods used:

Artificial Natural

condom rhythm method

pills withdrawal

spermicidal abstinence

Others: ____________________________________

Length of time used: __________________________

Complications: ______________________________

Gravidity: _____ Parity: _____

OB Index: _____________ Term

_____________ Preterm

_____________ Abortions/Miscarriages

_____________ Living ChildrenDate of Birth Sex Manner of Delivery

OB History: G ___ P ___ (T-P-A-L)

G1: When: __________, NSD or CS d/t: _________, delivered by

_________, where __________, M/F, weight __________, feto-

maternal complications __________, present status __________.

FAMILY HISTORYFamily

Member

Age Health/Diseases Age and

Date of Dx

Cause of

Death

Father

Mother

Others

Medical Problems for any blood-relative

Disease Relationship to Px Age and Date of

Dx

Cancer

HPN

Diabetes

TB

Heart Disease

Stroke

Kidney

Arthritis

Blood Disorder

Asthma

Epilepsy

Mental Disorder

Others

PERSONAL AND SOCIAL HISTORY

No. of years married: _________

No. of Children: _____________

Health Status of Children: __________

Highest Educational Attainment: _______________________

Occupational History: ________________________________

__________________________________________________

__________________________________________________

Occupational Hazards: _______________________________

Smoking Habits

non-smoker smoker ex-smoker

No. of sticks/packs per day: ___________________________

Year started: __________ Year quitted: __________

Alcohol Consumption

never occasionally daily weekly

Alcohol type: _____________________

Amount consumed: ________________

Nutrition

No. of meals per day: _______________

Food preferences: ____________________________

Coffee/Tea/Soda intake: _______________________

Nutrient Supplement: _________________________

OTC: ______________________________________________

Prohibited Drugs: ___________________________________

Substance Abuse: ___________________________________

Exercise: __________________________________________

Regularity of Sleep: __________________________________

Habits/hobbies: ____________________________________

Sources of stress: ___________________________________

Coping Strategies: ___________________________________

Living Conditions:

No. of years in current residence: _______________

Previous place of residence: ____________________

Type of residence: ___________________________

No. of rooms: _______________________________

No. of occupants: ____________________________

Relationship to occupants: _____________________

Source of Drinking Water: _____________________

Garbage Disposal: ____________________________

Fecal Disposal: ______________________________

Pet/s: ______________________________________

Personally gives bath to pets: Y/ N

General state of neighborhood: _________________

REVIEW OF SYSTEMS

Constitutional

Fever Weight gain/loss

Chills Fatigue

Skin

Rashes Itching

Lumps Dryness

Color change Changes in nails

Hair

Baldness Excess hair

Head

Headache Dizziness

Lightheadedness Trauma

Syncope Tenderness

Eyes

Pain Redness

Double vision Blurred vision

Use of glass/lenses Photalgia

Lacrimation

Ears

Hearing problem Earache

Discharge (color/consistency): ____________

Itching

Mouth and Throat

Use of dentures Mouth sores

Bleeding Gums Toothache

Sore throat Hoarseness

Dysphagia

Neck

Pain Stiffness

Lump

Breast

Pain Discharge

Lumps .Periodic exam

Respiratory

Cough Sputum color/quantity): ____

Hemoptysis Dyspnea

Wheezing

Cardiovascular

Chest pain Palpitations

Orthopnea Edema

Cyanosis Paroxysnal Nocturnal Dyspnea

Easy Fatigability

Gastrointestinal

Loss of appetite Nausea

Vomiting Hematemesis

Abdominal pain Diarrhea

Hematochezia Excessive belching/passing of gas

Renal

Dysuria Polyuria

Nocturia Gross Hematuria

Incontinence Urinary Retention

Urinary Urgency Tea-Colored Urine

In Males:

Reduced caliber of force of stream

Hesitancy

Dribbling

Genitalia

Pain Swelling

Discharge (characteristics): ___________________

Ulcers Itching

Peripheral Vascular

Leg cramps Varicose veins

Musculoskeletal

Muscle weakness Stiffness

Backache Joint swelling

Muscle pain Joint pain

Neurologic

Paralysis Numbness

Tremors Seizures

Memory Loss

Hematologic

Easy bruising Bleeding

Pallor

Endocrine

Polydipsia Polyphagia

Heat/cold intolerance Excessive sweating

Psychiatric

Nervousness Depression

Anxiety Hallucinations

PHYSICAL EXAMINATION

General Survey

Mood: ____________________________________________

Distress/Unusual Position: ____________________________

Cooperative / Non-cooperative: ________________________

Irritated / Agitated / Pleasant: _________________________

Coherent: _________________________________________

Oriented to time and space: ___________________________

Personal Hygiene: ___________________________________

Level of Consciousness: _______________________________

Height: ____________________________________________

Weight: ___________________________________________

BMI: ______________________________________________

Vital Signs

Temperature: _______ Oral Axillary Rectal

Respiration: ________ Normal Labored

Pulse: _____________ Regular R. Irregular Irr. irregular

Blood Pressure: _____ Lying Sitting Standing

Head

Trauma: ___________________________________________

Size: __________ Shape: ______________________

Tenderness: ________________________________________

Condition of hair and scalp: ___________________________

Symmetry: _________________________________________

Masses: ___________________________________________

Eyes

Visual Acuity:

Far: (R) _________ (L) _________

Near: (R) _________ (L) _________

Visual Fields (H-test): ________________________________

Accommodation: ____________________________________

Test of confrontation: ________________________________

Conjunctiva:

Color: ______________________________________

Discharge: __________________________________

Sclerae

Color: ______________________________________

Discharge: __________________________________

Cornea

Clarity: _____________________________________

Corneal Arcus: _______________________________

Lids: ______________________________________________

Position of eyes in orbits: _____________________________

Pupil

Size: (R) ____________ (L) _____________

Shape: _____________ Symmetry: ____________

Accommodation: ____________________________

Light reflex test (PERLA): ______________________

EOM: ______________________________________

Visual Field: _________________________________

Direct Reaction: ________ Consensual Reaction: _________

Fundoscopy

Red orange reflex: ___________________________

Disc: _______________________________________

Macula: ____________________________________

Blood vessels: _______________________________

Ears

Symmetry: _________________________________________

Swelling: _________________________________________

Redness: _________________________________________

Discharge: _______________________________________

Tenderness: ______________________________________

Hearing Impairments: ______________________________

Presence of Hearing Aid: ____________________________

Weber Test: ________________________________________

Rinne Test: (R) AC _______ (BC) _______

(L) AC _______ (BC) _______

Nose

Symmetry: _________________________________________

Frontal, Maxillary sinus tenderness: _____________________

Obstruction: _______________________________________

Congestion: ________________________________________

Lesions: ___________________________________________

Exudates: __________________________________________

Inflammation: ______________________________________

Throat

Lips: ______________________________________________

Teeth/dentures: ____________________________________

Gums: ____________________________________________

Tongue: ___________________________________________

Pharynx:

___________________________________________

Lesions: __________ Erythema: __________

Exudates: _________ Tonsillar size: _________

Neck

Symmetry: _________________________________________

Limitation of ROM: __________________________________

Tenderness: ________________________________________

JVP: ______________________________________________

Lymph nodes: ______________________________________

Size: _______________________________________

Mobility: ___________________________________

Tenderness: ________________________________

Borders: ___________________________________

Consistency: ________________________________

Thyroid Cartilage: _______ Cricoid cartilage: _______

Thyroid gland: ______________________________________

Chest and Lungs

Inspection

Comfort and Breathing Pattern: ________________________

Shape of the Chest: __________________________________

Chest Movement: ___________________________________

Use of Accessory Muscles of Breathing: ________________

Deformities of Asymmetry: __________________________

A/N Retraction of Interspaces on Inspiration: ____________

Impairment of Respiratory Movement: ________________

Color of Patient (Lips and Nail Bed): _____________________

Palpation

Tender Areas: _____________________________________

Respiratory Expansion (10th rib): Symmetry Yes No

Tactile Fremitus: Symmetry

Increased Decreased Absent

Percussion: ________________________________________

Auscultation

Breath Sounds:____________________________________

Bronchophony Whispered Pectoriloquy

Egophony

Heart

Inspection

Precordial bulge or heave: ____________________________

PMI: ______________________________________________

Palpation

PMI: ______________________________________________

Thrill: _____________________________________________

Location: ___________________________________

Timing in Cardiac Cycle (S/D): ___________________

Mode of Extension / Transmission: ______________

Friction Rub: ______________________________________

Percussion: Cardiac Borders

Right (cm) ICS/MSL Left (cm)

5th

4th

3rd

2nd

Auscultation

S1 (M-loud, T-split): __________________________________

S2 (A,P-loud, P-split I): ________________________________

S3: _______________________________________________

Murmurs/ Accessory Heart Sounds:

Location:_______________ Timing:______________

Quality:________________ Pitch:_______________

Intensity:_______________ Radiation:___________

Breast

Symmetry:_________________________________________

Dimpling/Skin Retraction:____________________________

Swelling:_________________________________________

Discoloration (Skin changes):_________________________

Orange Peel Effect:_________________________________

Position and Characteristics of Nipple:___________________

Gynecomastia (Male):_______________________________

Mass:

Location:___________________________________

Size: _____________ Consistency:_______________

Tenderness:___________ Mobility:______________

Borders:____________________________________

Abdomen

Inspection

Irregular Contours:___________________________ Scars

Discoloration: _____________________________________

Bulges: __________________________________________

Shape: ____________________________________________

Striae:___________________________________________

Distance of umbilicus from xiphoid process: ______________

Abdominal Girth:____________________________________

Auscultation

Bowel Sounds: Frequency:__________ Character:__________

Bruit:____________________________________________

Venous Hum:_____________________________________

Friction Rub:______________________________________

Percussion

Liver Span:__________________ Normal: 6-12 cm in (R) MCL

Splenic Dullness:____________________________________

Other Areas of Dullness: ______________________________

Special Tests

Rebound Tenderness: Rovsing’s / Blumberg

Costovertebral Tenderness

Shifting Dullness

Psoas Sign

Murphy’s Sign

Male Genitalia

Penile Lesions:____________________________________

Scrotal Swelling:___________________________________

Testicles

Size:_________ Tenderness:________________

Masses:___________________________________

Varicocoele:_______________________________

Hernia:__________________________________________

Transillumination: ___________________________________

Extremities

Amputation Visible joint swelling

Deformities Limitation of ROM

Tenderness Redness

Warmth Edema

Capillary refill: __________________________________

Peripheral pulses: _______________________________

NEUROLOGICAL EXAMINATION

Mental Status Examination

A. Awareness

Orientation

Name: Season Date Day Month Year

Name: Hospital Floor Town State Country

Level of Consciousness:

B. Speech (Normal, dysphasia, dysarthria, dysphonia)

C. Language

Name: Pencil Watch

Repeat: “ No ifs ands or buts”

D. General Knowledge

Knowledge of current events, vocabulary

(Historical events, 5 last presidents, 5 largest cities)

E. Memory

Immediate, recent, remote

F. Registration (Retention and Recall)

Identify: Object 1 Object 2 Object 3

Attention and Calculation

(100-7…): 93 86 79 72 65

Recall

Recall: Object 1 Object 2 Object 3

G. Reasoning

Judgment, Insight, Abstraction (interpretation of

proverbs)

H. Object Recognition

Agnosia (Visual, tactile, auditory autotopagnosia,

anosognosia)

Praxis (Ideomotor, Ideational)

Perception (Delusion, Hallucination, Illusion,

Astereognosis, Agraphestesia)

I. Follows Command

Take this paper. Fold it in half.

Place it on the table

Obey written Command.

Write a sentence

Copy a design.

Total: _____________________________________________

Cranial Nerve Examination

CN I

Identify odorant

CN II

Visual acuity:_____________ Visual Field: ________________

Fundoscopy: _______________________________________

CN III, IV, VI

Size and Shape of Pupil: ______________________________

Light Reaction Accommodation

EOM:

Paresis Nystagmus

Saccades Oculomotor Ataxia

Diplopia Other: _____________________

CN V

Ophthalmic Maxillary

Mandibular Corneal Reflex

Jaw Clench

CN VII

Eyebrow Elevation Forehead Wrinkling

Eye Closure Smiling

Cheek Puffing

CN VIII

Hear finger rub or whispered voice

Rinne:___________________ Weber: ___________________

CN IX, X

Palate and Uvula: ___________________________________

Gag Reflex

CN XI

Shoulder Shrug (against resistance)

Head Rotation (against resistance)

CN XII (Tongue)

Atrophy Fasciculation

Position with protrusion:______________________________

Strength:___________________________________________

Motor Examination

Involuntary Movements

Symmetry

Atrophy

Gait

Spasticity

Rigidity

Flaccidity

Clonus

Carpopedal Spasm

Tics

Tremors

Athetosis

Others

Tone

Description: ________________________________________

Flaccidity

Spasticity

Muscle Strength(R) (L)

Shoulder Flexion

Extension

Abduction

Adduction

IR/ER

Flexion at the Elbow

Extension at the elbow

Extension at the wrist

Squeeze 2 of your fingers as hard as possible

Finger Abduction

Opposition of the thumb

Flexion at the hips

Adduction at the hips

Abduction at the hips

Extension at the hips

IR/ER

Extension at the knee

Flexion at the knee

Dorsiflexion at the ankle

Plantar Flexion

Coordination and Gait

Rapid Alternating Movements

Point to point movements

Romberg

Gait

Walk across the room, turn and come back

Walk heel-to-toe in a straight line

Walk on heels in a straight line

Walk on toes in a straight line

Hop in place on each foot

Shallow knee band

Rise from a sitting position

Reflexes

Deep Tendon

Biceps

Triceps

Brachioradialis

Knee

Ankle

Superficial

Abdominal

Cremasteric

Reflexes in Infants

Grasp

Suck

Moro

Rooting

Tonic neck

Babinski

Sensory

Pin prick

Touch

Two point discrimination

Sense of Position

Vibratory Sense

Superficial sensation

Deep Sensation