HISTORY AND PHYSICAL EXAMINATION

Setting at which the Symptom Occurred:

Date of Interview:

__________________________________________________

___________________________________

__________________________________________________

Time of History:

Manifestations:

_____________________________________

Location:

Informant:

__________________________________________

_________________________________________

Precipitating Factors:

Relationship to the Patient:

________________________________

___________________________

Quality:

% Reliability:

___________________________________________

_______________________________________

Radiation:
_________________________________________

GENERAL DATA

Severity:

Patients Name:

___________________________________________

_____________________________________

Aggravating Factors:

Age: ___

_________________________________

_ Sex: ____ Marital Status:

_____________________

Alleviating Factors:

Address:

__________________________________

___________________________________________

Previous Treatment for the Problem:

Birthday: _____________

____________________

Birthplace:

____________
Nationality: ______________

Associated Signs and Symptoms:

Religion:

_______________________

______________

__________________________________________________

Occupation:

Pertinent Positives and Negatives:

________________________________________

_____________________
__________________________________________________

Date of Admission:

Additional Notes:

__________________________________

___________________________________

Time of Admission:

__________________________________________________

__________________________________

__________________________________________________

No. of times admitted at OMMC:

_______________________

PAST MEDICAL HISTORY

Current Medications:

CHIEF COMPLAINT

Generic

Brand

Dosage

__________________________________________________

Frequenc

Purpose

HISTORY OF PRESENT ILLNESS

Onset:
____________________________________________
Duration:
_________________________________________
Frequency:
_________________________________________

Immunizations:
BCG DPT Polio
Measles

Hepa B

Others:
____________________________________________
Allergies:
Food:
______________________________________

Test
Tuberculin Test
Pap Smear
Mammogram
Occult blood in

Date

Result

stool
Cholesterol test
Urinalysis
X-ray/CT

Medications:
________________________________
Pollen/Animals/Others:

Scan/MRI
Others

_______________________
Childhood Illness:
Rheumatic Fever

Polio

Chicken Pox

Measles

Mumps

LMP: ________________

Others:

Period:

Regular/Irregular

Adult Illness:
Age

PMP: ________________

Age of menarche: ____________

____________________________________

Illness

MENSTRUAL AND OBSTETRIC HISTORY

Date of
Diagnosis

HPN
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Others

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:
__________________________________________________
Surgical Procedures:

Birth control methods used:

Date:

Artificial

_____________________________________________

condom

rhythm method

Type of Operation:

pills

withdrawal

__________________________________

spermicidal

Purpose:
__________________________________________
Previous Hospitalizations:
Date

Cause

Hospital

Natural

Treatment

abstinence

Others:
____________________________________
Length of time used:
__________________________
Complications:
______________________________
Gravidity: _____
OB Index:

Screening Tests:

Parity: _____

_____________ Term
_____________ Preterm

_____________

Highest Educational Attainment:

Abortions/Miscarriages

_______________________

_____________ Living Children

Date of Birth

Sex

Occupational History:

Manner of

________________________________

Delivery

__________________________________________________
__________________________________________________
Occupational Hazards:
_______________________________
Smoking Habits

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

non-smoker

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

smoker

delivered by _________, where __________, M/F, weight

No. of sticks/packs per day:

__________, feto-maternal complications __________,

___________________________

present status __________.

Year started: __________

ex-smoker

Year quitted:

__________
FAMILY HISTORY
Family

Age

Member

Alcohol Consumption
Health/Diseas

Age and

Cause of

es

Date of

Death

never

daily

weekly

Dx

Father
Mother
Others

occasionally

Alcohol type: _____________________

Amount consumed: ________________
Nutrition
No. of meals per day: _______________
Food preferences:
____________________________
Coffee/Tea/Soda intake:

Medical Problems for any blood-relative

Disease

Relationship to

Age and Date

Px

of Dx

_______________________
Nutrient Supplement:

Cancer
HPN
Diabetes
TB
Heart Disease
Stroke
Kidney
Arthritis
Blood Disorder
Asthma
Epilepsy
Mental

_________________________

Disorder
Others

Regularity of Sleep:

OTC:
______________________________________________
Prohibited Drugs:
___________________________________
Substance Abuse:
___________________________________
Exercise:
__________________________________________
__________________________________
Habits/hobbies:
____________________________________

PERSONAL AND SOCIAL HISTORY

No. of years married: _________
No. of Children: _____________
Health Status of Children: __________

Sources of stress:
___________________________________
Coping Strategies:
___________________________________
Living Conditions:

No. of years in current residence:

Use of glass/lenses

_______________

Lacrimation

Previous place of residence:

Ears

____________________

Hearing problem

Type of residence:

Earache

Discharge (color/consistency):

___________________________

____________

No. of rooms:

Itching

_______________________________

Mouth and Throat

No. of occupants:

Use of dentures

____________________________

Mouth sores

Bleeding Gums

Relationship to occupants:

Sore throat

_____________________

Toothache
Hoarseness

Dysphagia

Source of Drinking Water:

Neck

_____________________

Pain

Garbage Disposal:
____________________________

Stiffness

Lump

Fecal Disposal:

Breast

______________________________

Pain

Pet/s:
______________________________________
Personally gives bath to pets: Y/ N
General state of neighborhood:
_________________

Discharge

Lumps

.Periodic

exam
Respiratory
Cough

Sputum

color/quantity): ____

REVIEW OF SYSTEMS

Hemoptysis

Constitutional
Fever

Weight gain/loss

Chills

Fatigue

Rashes

Itching

Lumps

Dryness

Color change

Changes in

nails

Dyspnea

Wheezing
Cardiovascular

Skin

Chest pain

Palpitations

Orthopnea

Edema

Cyanosis

Paroxysnal Nocturnal

Dyspnea

Easy Fatigability
Gastrointestinal

Hair
Baldness

Excess hair

Head
Headache

Dizziness

Loss of appetite

Nausea

Vomiting

Hematemesis

Abdominal pain

Diarrhea

Hematochezia

Lightheadedness

Trauma

belching/passing of gas

Syncope

Tenderness

Renal

Eyes
Pain
Double vision
vision

Photalgia

Redness
Blurred

Excessive

Dysuria

Polyuria

Nocturia

Gross Hematuria

Incontinence
Retention

Urinary

Urinary Urgency

Tea-Colored Urine

Irritated / Agitated / Pleasant:

_________________________

In Males:
Reduced caliber of force of

Coherent:
_________________________________________

stream

Oriented to time and space:

Hesitancy

___________________________

Dribbling

Personal Hygiene:

Genitalia
Pain

Swelling

Discharge (characteristics):

Level of Consciousness:
_______________________________

___________________
Ulcers

___________________________________

Itching

Peripheral Vascular

Height:
____________________________________________
Weight:

Leg cramps

Varicose veins

Musculoskeletal

___________________________________________
BMI:

Muscle weakness

Stiffness

Backache

Joint swelling

Muscle pain

Joint pain

Neurologic

______________________________________________
Vital Signs
Temperature: _______

Oral

Axillary

Rectal

Paralysis

Numbness

Respiration: ________

Normal

Labored

Tremors

Seizures

Pulse: _____________

Regular

R. Irregular

Memory Loss

Blood Pressure: _____ Lying

Hematologic
Easy bruising

Bleeding

Pallor

Sitting

Standing

Head
Trauma:
___________________________________________

Endocrine
Polydipsia

Polyphagia

Heat/cold intolerance

Excessive

Size: __________

Shape:

______________________
Tenderness:

sweating

________________________________________

Psychiatric

Condition of hair and scalp:

Nervousness
Anxiety

Depression
Hallucinations

___________________________
Symmetry:
_________________________________________

PHYSICAL EXAMINATION

Masses:

General Survey

___________________________________________

Mood:
____________________________________________

Eyes

Distress/Unusual Position:

Visual Acuity:

____________________________

Far:

Cooperative / Non-cooperative:

Near: (R) _________ (L) _________

________________________

Irr.

irregular

(R) _________ (L) _________

Visual Fields (H-test):

________________________________

Accommodation:
____________________________________

Blood vessels:
_______________________________

Test of confrontation:
________________________________

Ears

Conjunctiva:

Symmetry:

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:
____________________________________

_________________________________________
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:

Chest Movement:

____________________________________________

___________________________________

Tongue:

Use of Accessory Muscles of Breathing:

___________________________________________
Pharynx:

________________
Deformities of Asymmetry:

___________________________________________
Lesions: __________

Erythema:

__________

__________________________
A/N Retraction of Interspaces on Inspiration:
____________

Exudates: _________ Tonsillar size:

_________

Impairment of Respiratory Movement:

________________
Color of Patient (Lips and Nail Bed):

Neck

_____________________

Symmetry:

Palpation

_________________________________________

Tender Areas:

Limitation of ROM:

_____________________________________

__________________________________

Respiratory Expansion (10th rib): Symmetry

Tenderness:
________________________________________
JVP:

Yes

No
Tactile Fremitus: Symmetry
Increased

______________________________________________

Decreased

Absent

Lymph nodes:

Percussion:

______________________________________

________________________________________
Auscultation

Size:
_______________________________________

Breath Sounds:____________________________________

Mobility:
___________________________________

Bronchophony

Whispered Pectoriloquy

Egophony

Tenderness:
________________________________

Heart

Borders:
___________________________________

Inspection
Precordial bulge or heave:

Consistency:
________________________________

____________________________

Thyroid Cartilage: _______

PMI:

Cricoid cartilage:

_______

______________________________________________

Thyroid gland:

Palpation

______________________________________

PMI:
______________________________________________

Chest and Lungs

Thrill:

Inspection

_____________________________________________

Comfort and Breathing Pattern:

________________________
Shape of the Chest:
__________________________________

Location:
___________________________________
Timing in Cardiac Cycle (S/D):
___________________

Mode of Extension / Transmission:

______________

Tenderness:___________
Mobility:______________

Friction Rub:
Borders:____________________________________

______________________________________
Percussion: Cardiac Borders
Right (cm)

ICS/MSL
5th
4th
3rd
2nd

Left (cm)

Auscultation
S1 (M-loud, T-split):
__________________________________
S2 (A,P-loud, P-split I):
________________________________
S3:
_______________________________________________
Murmurs/ Accessory Heart Sounds:
Location:_______________
Timing:______________
Quality:________________
Pitch:_______________
Intensity:_______________
Radiation:___________

Abdomen
Inspection
Irregular Contours:___________________________
Scars
Discoloration: _____________________________________
Bulges:
__________________________________________
Shape:
____________________________________________

Striae:___________________________________________
Distance of umbilicus from xiphoid process:
______________
Abdominal
Girth:____________________________________
Auscultation
Bowel Sounds: Frequency:__________
Character:__________

Breast
Symmetry:_______________________________________

__

Bruit:____________________________________________

Dimpling/Skin

Venous

Retraction:____________________________

Hum:_____________________________________

Friction

Swelling:_________________________________________

Rub:______________________________________

Discoloration (Skin

Percussion

changes):_________________________
Orange Peel
Effect:_________________________________
Position and Characteristics of
Nipple:___________________
Gynecomastia
(Male):_______________________________
Mass:
Location:___________________________________
Size: _____________
Consistency:_______________

Liver Span:__________________ Normal: 6-12 cm in

(R) MCL
Splenic
Dullness:____________________________________
Other Areas of Dullness:
______________________________
Special Tests
Rebound Tenderness: Rovsings / Blumberg
Costovertebral Tenderness
Shifting Dullness
Psoas Sign
Murphys Sign

C. Language
Male Genitalia

Name: Pencil Watch

Penile

Repeat: No ifs ands or buts

Lesions:____________________________________

D. General Knowledge

Scrotal

Knowledge of current events, vocabulary

Swelling:___________________________________

(Historical events, 5 last presidents, 5

Testicles

largest cities)

Size:_________

E. Memory
Immediate, recent, remote

Tenderness:________________

F. Registration (Retention and Recall)

Identify: Object 1 Object 2 Object 3

Masses:___________________________________

Attention and Calculation

Varicocoele:_______________________________

(100-7): 93 86 79 72 65

Recall

Hernia:__________________________________________

Recall: Object 1 Object 2 Object 3

Transillumination:

G. Reasoning

___________________________________

Judgment, Insight, Abstraction

(interpretation of proverbs)
H. Object Recognition
Agnosia (Visual, tactile, auditory

Extremities

autotopagnosia, anosognosia)

Amputation

Visible joint swelling

Praxis (Ideomotor, Ideational)

Deformities

Limitation of ROM

Perception (Delusion, Hallucination,

Tenderness

Redness

Illusion, Astereognosis, Agraphestesia)

Warmth

Edema

I. Follows Command
Take this paper. Fold it in half.

Capillary refill:

Place it on the table

__________________________________

Obey written Command.

Peripheral pulses:

Write a sentence

_______________________________

Copy a design.
Total:

NEUROLOGICAL EXAMINATION

_____________________________________________

Mental Status Examination

A. Awareness

Cranial Nerve Examination

Orientation

CN I

Name: Season Date Day Month

Identify odorant

Year

CN II
Name: Hospital Floor Town State

Country
Level of Consciousness:

Visual acuity:_____________ Visual Field:

________________
Fundoscopy:

B. Speech (Normal, dysphasia, dysarthria,

_______________________________________

dysphonia)

CN III, IV, VI

Size and Shape of Pupil:

Flaccidity

______________________________

Clonus

Light Reaction

Carpopedal Spasm

Accommodation

EOM:

Tics

Paresis

Nystagmus

Saccades

Oculomotor Ataxia

Diplopia

Other:

_____________________
CN V
Ophthalmic

Maxillary

Mandibular

Corneal Reflex

Tremors
Athetosis
Others
Tone
Description:
________________________________________

Jaw Clench

Flaccidity

CN VII

Spasticity

Eyebrow Elevation Forehead Wrinkling

Eye Closure

Smiling

Muscle Strength

Cheek Puffing

(R)

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:______________________________

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

Strength:_________________________________________
__

Coordination and Gait

Rapid Alternating Movements

Motor Examination

Point to point movements

Involuntary Movements

Romberg

Symmetry

Gait

Atrophy

Walk across the room, turn and come back

Gait

Walk heel-to-toe in a straight line

Spasticity

Walk on heels in a straight line

Rigidity

Walk on toes in a straight line

(L)

 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