HISTORY AND PHYSICAL EXAMINATION

Additional Notes: ___________________________________

Date of Interview: ___________________________________

__________________________________________________

Time of History: _____________________________________

__________________________________________________

Informant: _________________________________________
Relationship to the Patient: ___________________________

PAST MEDICAL HISTORY

% Reliability: _______________________________________

Current Medications:
Generic

Brand

Dosage

Frequency

Purpose

GENERAL DATA
Patients Name: _____________________________________
Age: ___ _ Sex: ____ Marital Status: _____________________
Address: ___________________________________________
Birthday: _____________

Birthplace: ____________

Nationality: ______________

Religion: ______________

Occupation: ________________________________________

Immunizations:
BCG

DPT

Polio Hepa B Measles

Date of Admission: __________________________________

Others: ____________________________________________

Time of Admission: __________________________________

Allergies:

No. of times admitted at OMMC: _______________________

Food: ______________________________________
Medications: ________________________________

CHIEF COMPLAINT
__________________________________________________

Pollen/Animals/Others: _______________________
Childhood Illness:
Rheumatic Fever

Polio

HISTORY OF PRESENT ILLNESS

Chicken Pox

Measles

Onset: ____________________________________________

Mumps

Duration: _________________________________________

Others: ____________________________________

Frequency: _________________________________________

Adult Illness:

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: _____________________
__________________________________________________

Illness
HPN
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Others

Age

Date of Diagnosis

Surgical Procedures:

Length of time used: __________________________

Date: _____________________________________________

Complications: ______________________________

Type of Operation: __________________________________

Gravidity: _____

Purpose: __________________________________________

OB Index:

_____________ Term

Previous Hospitalizations:
Date

Parity: _____
_____________ Preterm

Cause

Hospital

_____________ Abortions/Miscarriages

Treatment

_____________ Living Children

Date of Birth

Sex

Manner of Delivery

Screening Tests:
Test

Date

Result

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

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

Tuberculin Test

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

Pap Smear

maternal complications __________, present status __________.

Mammogram
Occult blood in stool

FAMILY HISTORY

Cholesterol test

Family

Urinalysis

Member

X-ray/CT Scan/MRI

Father

Others

Mother

Age

Health/Diseases

Age and

Cause of

Date of Dx

Death

Others

MENSTRUAL AND OBSTETRIC HISTORY

LMP: ________________

PMP: ________________

Age of menarche: ____________

Period: Regular/Irregular

Character of flow: ___________________________________

Medical Problems for any blood-relative

Disease

Duration of period (range): ____________________________

Cancer

PMS: _____________________________________________

HPN

Age of Menopause: _________

Diabetes

Age of 1st coitus: _____

TB

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

Heart Disease

__________________________________________________

Stroke

Birth control methods used:

Kidney

Artificial

Natural

condom

rhythm method

pills

withdrawal

spermicidal

abstinence

Others: ____________________________________

Age and Date of

Dx

No. of pads used per day: _____________________________

No. of sexual partners: _____

Relationship to Px

Arthritis
Blood Disorder
Asthma
Epilepsy
Mental Disorder

Garbage Disposal: ____________________________

Others

Fecal Disposal: ______________________________

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

PERSONAL AND SOCIAL HISTORY

No. of years married: _________
No. of Children: _____________

REVIEW OF SYSTEMS

Health Status of Children: __________

Constitutional

Highest Educational Attainment: _______________________

Fever

Weight gain/loss

Occupational History: ________________________________

Chills

Fatigue

__________________________________________________

Rashes

Itching

Occupational Hazards: _______________________________

Lumps

Dryness

Smoking Habits

Color change

Changes in nails

Baldness

Excess hair

Headache

Dizziness

Lightheadedness

Trauma

Syncope

Tenderness

__________________________________________________

non-smoker

smoker

ex-smoker

Skin

Hair

No. of sticks/packs per day: ___________________________

Year started: __________

Year quitted: __________

Head

Alcohol Consumption
never

occasionally

daily

weekly

Alcohol type: _____________________

Amount consumed: ________________

Eyes

Nutrition

Pain

Redness

No. of meals per day: _______________

Double vision

Blurred vision

Food preferences: ____________________________

Use of glass/lenses

Photalgia

OTC: ______________________________________________

Hearing problem

Earache

Prohibited Drugs: ___________________________________

Discharge (color/consistency): ____________

Substance Abuse: ___________________________________

Itching

Coffee/Tea/Soda intake: _______________________

Nutrient Supplement: _________________________

Exercise: __________________________________________

Ears

Mouth and Throat

Regularity of Sleep: __________________________________

Use of dentures

Mouth sores

Habits/hobbies: ____________________________________

Bleeding Gums

Toothache

Sore throat

Hoarseness

Sources of stress: ___________________________________

Coping Strategies: ___________________________________
Living Conditions:
No. of years in current residence: _______________

Dysphagia
Neck
Pain

Previous place of residence: ____________________

Type of residence: ___________________________
No. of rooms: _______________________________
No. of occupants: ____________________________
Relationship to occupants: _____________________
Source of Drinking Water: _____________________

Stiffness

Lump
Breast
Pain

Discharge

Lumps

.Periodic exam

Respiratory

Endocrine

Cough

Sputum color/quantity): ____

Polydipsia

Polyphagia

Hemoptysis

Dyspnea

Heat/cold intolerance

Excessive sweating

Wheezing

Psychiatric

Cardiovascular
Chest pain

Palpitations

Orthopnea

Edema

Cyanosis

Paroxysnal Nocturnal Dyspnea

Easy Fatigability

Nervousness

Depression

Anxiety

Hallucinations

PHYSICAL EXAMINATION
General Survey
Mood: ____________________________________________

Gastrointestinal
Loss of appetite

Nausea

Distress/Unusual Position: ____________________________

Vomiting

Hematemesis

Cooperative / Non-cooperative: ________________________

Abdominal pain

Diarrhea

Irritated / Agitated / Pleasant: _________________________

Hematochezia

Excessive belching/passing of gas

Coherent: _________________________________________
Oriented to time and space: ___________________________

Renal
Dysuria

Polyuria

Personal Hygiene: ___________________________________

Nocturia

Gross Hematuria

Level of Consciousness: _______________________________

Incontinence

Urinary Retention

Height: ____________________________________________

Urinary Urgency

Tea-Colored Urine

Weight: ___________________________________________
BMI: ______________________________________________

In Males:
Reduced caliber of force of stream
Hesitancy

Vital Signs

Dribbling

Temperature: _______

Oral Axillary Rectal

Respiration: ________

Normal Labored

Pulse: _____________

Regular R. Irregular Irr. irregular

Blood Pressure: _____

Lying Sitting Standing

Genitalia
Pain

Swelling

Discharge (characteristics): ___________________

Ulcers

Itching
Head

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
Pallor

Bleeding

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:

Exudates: __________________________________________

Color: ______________________________________

Inflammation: ______________________________________

Discharge: __________________________________
Sclerae

Throat
Color: ______________________________________

Lips: ______________________________________________

Discharge: __________________________________

Teeth/dentures: ____________________________________

Cornea

Gums: ____________________________________________
Clarity: _____________________________________

Tongue: ___________________________________________

Corneal Arcus: _______________________________

Pharynx: ___________________________________________

Lids: ______________________________________________

Lesions: __________

Erythema: __________

Position of eyes in orbits: _____________________________

Exudates: _________

Tonsillar size: _________

Pupil
Size: (R) ____________

(L) _____________

Neck

Shape: _____________

Symmetry: ____________

Symmetry: _________________________________________

Accommodation: ____________________________

Limitation of ROM: __________________________________

Light reflex test (PERLA): ______________________

Tenderness: ________________________________________

EOM: ______________________________________

JVP: ______________________________________________

Visual Field: _________________________________

Lymph nodes: ______________________________________

Direct Reaction: ________ Consensual Reaction: _________

Size: _______________________________________

Fundoscopy

Mobility: ___________________________________

Red orange reflex: ___________________________

Tenderness: ________________________________

Disc: _______________________________________

Borders: ___________________________________

Macula: ____________________________________

Consistency: ________________________________

Blood vessels: _______________________________

Thyroid Cartilage: _______

Cricoid cartilage: _______

Thyroid gland: ______________________________________

Ears
Symmetry: _________________________________________

Chest and Lungs

Swelling: _________________________________________

Inspection

Redness: _________________________________________

Comfort and Breathing Pattern: ________________________

Discharge: _______________________________________

Shape of the Chest: __________________________________

Tenderness: ______________________________________

Chest Movement: ___________________________________

Hearing Impairments: ______________________________

Use of Accessory Muscles of Breathing: ________________

Presence of Hearing Aid: ____________________________

Deformities of Asymmetry: __________________________

Weber Test: ________________________________________

A/N Retraction of Interspaces on Inspiration: ____________

Rinne Test:

(R) AC _______

(BC) _______

Impairment of Respiratory Movement: ________________

(L) AC _______

(BC) _______

Color of Patient (Lips and Nail Bed): _____________________

Nose

Palpation

Symmetry: _________________________________________

Tender Areas: _____________________________________

Frontal, Maxillary sinus tenderness: _____________________

Respiratory Expansion (10 rib): Symmetry Yes No

Obstruction: _______________________________________

Tactile Fremitus: Symmetry

Congestion: ________________________________________

Increased

Lesions: ___________________________________________

th

Decreased

Absent

Percussion: ________________________________________

Auscultation

Size: _____________ Consistency:_______________

Breath Sounds:____________________________________

Tenderness:___________ Mobility:______________

Bronchophony

Borders:____________________________________

Whispered Petoriloquy

Egophony
Abdomen
Heart

Inspection

Inspection

Irregular Contours:___________________________ Scars

Precordial bulge or heave: ____________________________

Discoloration: _____________________________________

PMI: ______________________________________________

Bulges: __________________________________________

Palpation

Shape: ____________________________________________

PMI: ______________________________________________

Striae:___________________________________________

Thrill: _____________________________________________

Distance of umbilicus from xiphoid process: ______________

Location: ___________________________________

Abdominal Girth:____________________________________

Timing in Cardiac Cycle (S/D): ___________________

Auscultation

Mode of Extension / Transmission: ______________

Bowel Sounds: Frequency:__________ Character:__________

Friction Rub: ______________________________________

Bruit:____________________________________________

Percussion: Cardiac Borders

Venous Hum:_____________________________________

Right (cm)

ICS/MSL

Left (cm)

th

Friction Rub:______________________________________
Percussion

th

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

rd

Splenic Dullness:____________________________________

nd

Other Areas of Dullness: ______________________________

4
3
2
Auscultation

Special Tests

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

Rebound Tenderness: Rovsings / Blumberg

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

Costovertebral Tenderness

S3: _______________________________________________

Shifting Dullness

Murmurs/ Accessory Heart Sounds:

Psoas Sign

Location:_______________ Timing:______________

Murphys Sign

Quality:________________ Pitch:_______________
Intensity:_______________ Radiation:___________

Male Genitalia
Penile Lesions:____________________________________

Breast

Scrotal Swelling:___________________________________

Symmetry:_________________________________________

Testicles

Dimpling/Skin Retraction:____________________________

Size:_________ Tenderness:________________

Swelling:_________________________________________

Masses:___________________________________

Discoloration (Skin changes):_________________________

Varicocoele:_______________________________

Orange Peel Effect:_________________________________

Hernia:__________________________________________

Position and Characteristics of Nipple:___________________

Transillumination: ___________________________________

Gynecomastia (Male):_______________________________
Mass:
Location:___________________________________

 Place it on the table

Extremities
Amputation

Visible joint swelling

Obey written Command.

Deformities

Limitation of ROM

Write a sentence

Tenderness

Redness

Copy a design.

Warmth

Edema

Total: _____________________________________________

Capillary refill: __________________________________

Cranial Nerve Examination

Peripheral pulses: _______________________________

CN I
Identify odorant

NEUROLOGICAL EXAMINATION

CN II

Mental Status Examination

Visual acuity:_____________ Visual Field: ________________

A. Awareness

Fundoscopy: _______________________________________

Orientation

CN III, IV, VI

Name: Season Date Day Month Year

Size and Shape of Pupil: ______________________________

Name: Hospital Floor Town State Country

Light Reaction

Level of Consciousness:

EOM:

Accommodation

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

Paresis

Nystagmus

C. Language

Saccades

Oculomotor Ataxia

Name: Pencil Watch

Diplopia

Other: _____________________

Repeat: No ifs ands or buts

CN V
Ophthalmic

Maxillary

Knowledge of current events, vocabulary

Mandibular

Corneal Reflex

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

Jaw Clench

D. General Knowledge

E. Memory
Immediate, recent, remote
F. Registration (Retention and Recall)

CN VII
Eyebrow Elevation

Forehead Wrinkling

Eye Closure

Smiling

Identify: Object 1 Object 2 Object 3

Cheek Puffing

Attention and Calculation

CN VIII

(100-7): 93 86 79 72 65

Hear finger rub or whispered voice

Recall

Rinne:___________________ Weber: ___________________

Recall: Object 1 Object 2 Object 3

CN IX, X

G. Reasoning

Palate and Uvula: ___________________________________

Judgment, Insight, Abstraction (interpretation of

Gag Reflex

proverbs)

CN XI

H. Object Recognition

Shoulder Shrug (against resistance)

Agnosia (Visual, tactile, auditory autotopagnosia,

Head Rotation (against resistance)

anosognosia)

CN XII (Tongue)

Praxis (Ideomotor, Ideational)

Atrophy

Perception (Delusion, Hallucination, Illusion,

Position with protrusion:______________________________

Astereognosis, Agraphestesia)

Strength:___________________________________________

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

Fasciculation

Motor Examination

Plantar Flexion

Involuntary Movements
Symmetry

Coordination and Gait

Atrophy

Rapid Alternating Movements

Gait

Point to point movements

Spasticity

Romberg

Rigidity

Gait

Flaccidity

Walk across the room, turn and come back

Clonus

Walk heel-to-toe in a straight line

Carpopedal Spasm

Walk on heels in a straight line

Tics

Walk on toes in a straight line

Tremors

Hop in place on each foot

Athetosis

Shallow knee band

Others

Rise from a sitting position

Tone

Reflexes

Description: ________________________________________

Deep Tendon

Flaccidity

Biceps

Spasticity

Triceps
Brachioradialis
Knee

Muscle Strength
(R)
Shoulder Flexion

(L)

Ankle
Superficial

Extension

Abdominal

Abduction

Cremasteric

Adduction

Reflexes in Infants

IR/ER

Grasp

Flexion at the Elbow

Suck

Extension at the elbow

Moro

Extension at the wrist

Rooting

Squeeze 2 of your fingers as hard as possible

Tonic neck

Finger Abduction

Babinski

Opposition of the thumb

Flexion at the hips

Sensory

Adduction at the hips

Pin prick

Abduction at the hips

Touch

Extension at the hips

Two point discrimination

IR/ER

Sense of Position

Extension at the knee

Vibratory Sense

Flexion at the knee

Superficial sensation

Dorsiflexion at the ankle

Deep Sensation