Date/ time of history taken: ________ Informant: ____________ Reliability: ___________

Interviewer: _______________ source of referral: ___________

I. Identifying data: III. HPI
Name: Age: O:
Sex: Birth place P:
B-day Marital Q:
status S:
Religion Address T:
Occupatio Accompanying
n symptoms

II. Chief complaint:

III. HPI:

IV. Interval history( chronic cases)

V. Medications:

VI. Past medical : VII. Personal social

Childhood illness Surgeries: Smoking Pack years

Quit ( since when)
hospitalization: Alcohol
Obstetrics: Living #windows
Allergy: condition Location of house
ADL
TRAVEL

VII. Family history: IX. sexual reproductive

Woman Man : any dysfunction
GP(TPAL):
menarche
Pads/ soaked?
Days
Symptoms:
X. ROS:
 System Findings
GENERAL ( )Usual Weight
( )Weakness ( )Recent weight change
( )Fatigue ( )Clothing that fits more
( )Fever tightly or Loosely than
before
SKIN ( ) Rashes
( ) Changes Color ( ) Lumps
( )Changes in hair or ( ) Sores
Nails ( ) Itching
( )Changes in Size or ( ) Dryness
Color of moles
HEAD, EYES, EARS, HEAD:
NOSE, THROAT ( ) Headache,
(HEENT) ( ) Head Injury,
( ) Dizziness
Nose and sinus
( ) lightheadedness
( ) frequent colds
EYES:
( ) nasal stuffiness
/20 Vision,
( ) discharge or itching
( ) glasses
Throat or mouth or
Ears
pharynx
( hearing
( ) Complete set of
( ) Tinnitus
baby /adult teeth
( ) Earaches
( ) dental caries
( )lesions
( ) bleeding gums
( ) infection
( ) discharge
NECK ( )Swollen glands
( )Goiter
( )Lumps
( )Pain stiffness in the neck
BREAST Unremarkable
RESPIRATORY ( )Cough
( )Dyspnea ( )Sputum
( )Wheezing Last chest x-ray ( )
( )Hemoptysis
CARDIOVASCULAR ( )Heart trouble
( )Heart murmurs ( )High blood pressure
( )Dyspnea ( )chest pain palpitations
( )Orthopnea ( )Paroxysmal nocturnal
( )Edema dyspnea
GASTROINTESTINAL ( )Trouble swallowing
( )Hemorrhoids ( )Heartburn
( )Constipations ( )Change in bowel
( )Diarrhea movements
( )Abdominal pain ( )Pain tight defection
( )Food intolerance ( )Excessive belching or
( )Jaundice passing of gas
( )Nausea ( )Liver or gallbladder
( )Hepatitis trouble
( ) Bowel movements
URINARY Frequency of urination
( )Burning or pain ( )Polyuria
during urination ( )Nocturnal
( )Hematuria ( )Urgency
( )Urinary infections ( )Kidney or flank pain
GENITAL

MUSCULOSKELETAL ( ) Muscle or joint pain

( )fever ( )Stiffness
( )Chills ( )Gout
( )Rash ( )Backache
( )Anorexia ( )Neck pain
( )Weight loss ( )Edema
PSYCHIATRIC ( )Nervousness
( )Tension
NEUROLOGIC ( ) Changes in mood
( )Blackouts ( ) attention
( )Weakness ( )Headache
( )Paralysis ( )Dizziness
( )Numbness ( )Vertigo
( )Tingling “pins and ( )Fainting
needles ( )Tremors
HEMATOLOGIC ( ) pallor
( )Easy bruising
( )Bleeding
ENDOCRINE ( )Thyroid trouble
( )Heat intolerance
( )Excessive sweating
( )Polyuria
( )Change in shoe size

PHYSICAL ASSESSMENT
Date of Assessment:
General Appearance:

Level of Orientation
consciousness
Vs
T: P : R: BP:
O2sat :
Cleanliness:

Exam proper
 BODY PART Scars Shape:
A. HEAD ( )Discharges Lesions:
1. SKULL ( )Deformities
Proportional? ( )Inflammation
Symmetrical: 1. otoscopy
2. EAR CANAL Odor :
2. SCALP ( )White, Lesions :
( )scars, ( )free from Ear drum: Scales:
( )dandruff, masses, Color: Foreign body :
( ) lesion/ loc. ( ) lumps, Sheen
hair loss Inflammation:
3. HAIR Distribution: 3. hearing acuity ( ) Weber’s
Consistency: Color : AC BC : Rinnes
( ) Whispered voice
test
4. FACE Shape :
( )Symmetrical ( )Balance of mood D. NOSE ( )Symmetry
( )Inflammations Patency:
( )Abnormal and facial expression
movement ( )Temporal arteries ( ) Nasal flaring
( ) lesions ( ) TMJ 1. INTERNAL Color :
( ) mass / NARES Discharges:
inflammation 2. sinuses ( )Translumination
B. EYES Color:
1.EYEBROWS ( )Symmetrical
Distribution:
E. MOUTH Color:
2. EYELIDS Coverage:
Symmetry( )
( )Symmetry
Moisture ( )
Color:
1. LIPS Discharges :
3. LID MARGINS Scales :
Inflammation:
Secretions :
Color :
Inflammation:
( ) Scales
4. CONJUNCTIVA Color: 2. TEETH
( )Lesions
( )Secretions: 3. TONGUE Color:
Vascularity:
4. SCLERA White and clear. Movement:
5. IRIS Symmetry Symmetry:
Color 4. CHEEKS Color:
6. PUPIL ( )PERRLA (BUCCAL Vascularity.
( )Direct MUCOSA) Lesions:
( )Indirect Inflammation:
Size: mm - mm 5. PALATE
7. CORNEA Color:  SOFT PALATE Color:
8. FUNDUSCOPIC Vascularity:
RESULT  HARD PALATE
9. EYE 6. UVULA Symmetry:
MOVEMENT Color:
C. EARS Size: Vascularity:
7. TONSILS ( )Inflammation bronchovesicular
( )secretions breath sounds.
L. UPPER
8. VOICE ( )Hoarseness EXTREMITIES
1. ARMS Skin varies (pinkish,
F. NECK Nodes: Inspection hair distribution:
Thyroid gland Skin color:
G. RANGE OF Symmetry:
MOTION
H. MUSCULAR Palpation Temp:
STRENGTH Moisture
Tenderness :
Lesions:
I. HEART Rhythm:
HR:
J. ABDOMEN M. NAILS Transparency:
Inspection Moisture :
1. Abdomen skin Lesions:
Color Clubbing:
2. Contour and Capillary refill:
Symmetry
N. SHOULDERS, Ease:
3. Movements ARMS, ELBOWS, Crepitus
associated w/ Symmetric HANDS & WRISTS DTR:
respiration movements caused ABDUCTION AND
by respiration. ADDUCTION.
O. LOWER
EXTREMITIES
Auscultation Sounds:
1. LEGS Color :
# of BS:
Inspection Hari distribution:
Abnomalites ?
varicosities
Symmetry
Wasting:
Palpation Tenderness?

Lesions
Palpation Temp:
Tone:
K. CHEST
(THORAX) Symmetry:
2. TOES
Inspection Expansion:
Inspection Toes completion
Tone
Palpation Tactile fremitus:
Color
Nailbed
Symmetry:
Palpation Capillary refill
Percussion Resonant:
Abnormalities:
P. LEGS, KNEES, Crepitus
ANKLES, TOES DTR:
Auscultation Vesicular or
ADDUCTION AND Seatbelts, helmets, sports safety measures,
ABDUCTION. hazardous activities, driving while
Q. PERINEUM Dishcages
Color:
intoxicated
Sexuality/Sexual identity
R. BUTTOCKS Mass
Tenderness Reproductive health (use of contraceptives,
Lesions:

presence of sexually transmitted infections,

Home
feelings, pregnancy)
Space,
Family and Friends
privacy,
Family constellation, genogram,
frequent geographic moves, single/married/separated/divorced/blended
neighborhood family, family occupations and shifts,

Education/School
Frequent school changes, history of addiction in the 1st and 2nd
degree relatives, parental attitude toward
repetition of a grade in each subject, alcohol and drugs, parental rules;
teacher’s reports, vocational goals, after-
school educational clubs
chronically ill physically or mentally
(language, speech, math,etc)
challenged parent.

learning disabilities
Abuse
Physical, sexual, emotional, verbal abuse;
parental discipline
Drugs
Tobacco, alcohol, marijuana, inhalants,
“Club drugs”, “rave”parties, others. Drugs of
choice, age at initiation, frequency mode of
intake, rituals alone or with peers, quit
methods, and number of attempts
Safety
Friends: peer cliques and configuration
(“preppies”, jocks,” ”nerds”, ”computer
geeks” cheerleaders) gang or cult affiliation
Image
Height and weight perceptions, body
musculature and physique, appearance
(including dress, jewelry and tattoos, body
piercing as fashion trends or other
statement)
Recreation
Sleep,
exercise,
Organized or unstructured sports,
recreational activities
Spirituality Connectedness
Adherence,
rituals,
occult practices, community service or
involvement
Threats and violence
Self harm or harm to others, running away,
cruelty to animals, guns, fights, arrests,
stealing, fire setting, fights in school