PRE-RESIDENTS

CLINICAL HISTORY

Last Name First Name Middle Name Room/Bed No. Hospital No.:
Patient ID:
Attending Physician: Age: Sex: Civil Status: Religion:

Chief Complaint: ____________________________________________________________________________
History of Present Illness: ____________________________________________________________________
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Past Medical / Surgical History:
( ) Hypertension ( ) Diabetes Mellitus ( ) Asthma ( ) Hepatitis
Others: _____________________________________________________________________________
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Previous Operations: ___________________________________________________________________
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Medications Taken: _________________________________________________________________________
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Allergies: Food: _________________________________ Drug: _____________________________________

Family History:
( ) Hypertension ( ) Kidney Disease
( ) Diabetes Mellitus ( ) Asthma
( ) Cancer ( ) Heart Disease
Others ______________________________________________________________________________

Personal / Social History: _____________________________________________________________________
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Review of Systems:
( ) Weight loss ( ) Diarrhea ( ) Chest pain ( ) Dysuria
( ) Fever ( ) Constipation ( ) Difficulty breathing ( ) Hematuria
( ) Easy fatigability ( ) Nausea / Vomiting ( ) Orthopnea Others:
( ) Cough / Colds ( ) Difficulty swallowing ( ) Paroxysmal nocturnal dyspnea

PHYSICAL EXAMINATION:
General Survey: ____________________________________________________________________________
Vital Signs: BP: ______/______ PR: ______ RR: _____ Temp: _____OC Wt: _____ kg Ht: ______ cm BMI: ______
Skin: _____________________________________________________________________________________
HEENT: ___________________________________________________________________________________
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Visual Acuity (Ophtha): ______________________________________________________________________
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Neck: _____________________________________________________________________________________
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Chest / Lungs: ______________________________________________________________________________
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Heart: ____________________________________________________________________________________
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Abdomen: _________________________________________________________________________________
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Rectal Exam: _______________________________________________________________________________
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Pelvic Exam: _______________________________________________________________________________
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Extremities: _______________________________________________________________________________
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Neurological Exam: __________________________________________________________________________
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IMPRESSIONS: _____________________________________________________________________________
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Informant: Accomplished by:
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Name relation to patient