HISTORY AND PHYSICAL EXAMINATION Medications: ________________________________

Pollen/Animals/Others: ______________________
Date of Interview: _______________________________________ Childhood Illness:
Time of History: _________________________________________ Rheumatic Fever - Age & Date of Diagnosis ____________
Informant: _______________________________________________ Polio - Age & Date of Diagnosis _____________
Relationship to the Patient: ____________________________ Chicken Pox - Age & Date of Diagnosis _____________
% Reliability: ____________________________________________ Measles - Age & Date of Diagnosis _____________
Source of Referral ______________________________________ Mumps - Age & Date of Diagnosis _____________
Others: ____________________________________
I. GENERAL DATA
Patient’s Name: __________ Adult Illness:
Age: __ ___ Sex: ___ __ Marital Status: ________________ Illness Age Date of Diagnosis
Address: _________________ HPN
Birthday: ________ Birthplace: ____________ Stroke
Nationality: ______ Religion: _____________ Renal
Occupation: ______ Asthma
Date of Admission/Consultation: ___________________________
TB
Time of Admission/Consultation: _______
DM
No. of times admitted: _
Cardiac
GI
II. CHIEF COMPLAINT
STD
_________________________________
Psychiatric (Depression,
P: ________________________________
Q: ________________________________ Anxiety, Suicidal Attempts)
R: ________________________________
S: ________________________________
T: ________________________________
Surgical Procedures:
Date: _____________________________________________
III. HISTORY OF PRESENT ILLNESS
Type of Operation: _____________________________
1. _________ ________________________
Kind of Injury: __________________________________
Onset: _________ ________________________
Purpose: ________________________________________
Duration: ________
Previous Hospitalizations:
Frequency: _______
Date Cause Hospital Treatment
Location: ________________
Precipitating Factors: ________________________________
Quality: _________________
Radiation: ________________________
Severity: __
Aggravating Factors: ______
Alleviating Factors:___________________________________________ Screening Tests:
Previous Treatment for the Problem: ______________________ Test Date Result
Associated Signs and Symptoms: Tuberculin Test
________________________________________ ___________ Pap Smear
Mammogram
Occult blood in stool
Additional Notes: Cholesterol test
________________ Urinalysis
_________ X-ray/CT Scan/MRI
Coagulation Test

IV. PAST MEDICAL HISTORY

V. MENSTRUAL AND OBSTETRIC HISTORY
Current Medications: LMP: ________________ PMP: ________________
Generic Brand Dosage Frequency Purpose Age of menarche: ____________ Period: Regular/Irregular
Character of flow: ___________________________________
Duration of period (range): ____________________________
No. of pads used per day: _____________________________
PMS: _____________________________________________
Age of Menopause: _________
Immunizations: Age of 1st coitus: _____ No. of sexual partners: _____
BCG DPT Polio Hepa B Measles History of post-coital bleeding, pelvic infection, dyspareunia:
Others: ____________________________________________ __________________________________________________
Birth control methods used:
Allergies: Artificial Natural
Food: ______________________________________
Page 1 of 7
 condom rhythm method Smoking Habits
pills withdrawal non-smoker smoker ex-smoker
spermicidal abstinence No. of sticks/packs per day: ______________________________
Others: ____________________________________ Year started: __________ Year quitted: ___________
Length of time used: __________________________
Complications: ______________________________ Alcohol Consumption
Gravidity: _____ Parity: _____ never ocassionally daily weekly
OB Index: _____________ Term Alcohol type: ______
_____________ Preterm Amount consumed: ________________________
_____________ Abortions/Miscarriages Nutrition
_____________ Living Children No. of meals per day:______________
Date of Birth Sex Manner of Delivery Food preferences:
Coffee/Tea/Soda intake: ______________________
Nutrient Supplement: ______________________________
OTC: _______________________________________________ ____________
OB History: G ___ P ___ (T-P-A-L) Prohibited Drugs: __________________________________
G1: When: __________, NSD or CS d/t: _________, delivered by _________, Substance Abuse: ___________________________________
where __________, M/F, weight __________, feto-maternal Exercise:__________________
complications __________, present status __________. Regularity of Sleep:________________________
HIV Awareness: ________________________________________________________ Interests: ______________________________________________________
Strengths: _____________________________________________________
VI. FAMILY HISTORY Habits/hobbies: ____________________________________
Sources of stress: __ ________________________
Family Age Health/Diseases Age and Cause of Sources of support:___________________________________________
Member Date of Death Coping Strategies: ________ __ ______________________________
Dx Military Service: ______________________________________________
Father Retirement: ___________________________________________________
Religious Affliation: __________________________________________
Mother
Safety Measures: _____________________________________________
Others
Alternative Healthcare Practices: __________________________

Living Conditions:
Medical Problems for any Blood-Relative
No. of years in current residence: _______________
Disease Relationship to Px Age and Date of
Previous place of residence: ______________________
Dx
Type of residence: ________ ______________________
Cancer No. of rooms: ______________________________________
HPN No. of occupants: __________________________________
Diabetes Relationship to occupants: ________________ _____
TB Source of Drinking Water: ________________________
Heart Disease Water Supply: _____________________________________
Stroke Garbage Disposal: _____________ ___________________
Kidney Fecal Disposal: ____ ___________
Arthritis Type 1/2/3
Blood Disorder Pet/s: ______________________________________________
Asthma Personally gives bath to pets: Y/ N
Epilepsy General state of neighborhood: __________
Mental Disorder __________
Galbladder dse
Substance Abuse VIII. REVIEW OF SYSTEMS
Thyroid Disease Constitutional
Renal Disease Fever
Hypercholesterolemia Weight gain/loss
Allergy Chills Fatigue
Suicide Skin
Rashes Itching
VII. PERSONAL AND SOCIAL HISTORY Lumps Dryness
No. of years married: ______ Color change Changes in nails
No. of Children: _____ _____ Hair
Health Status of Children: _________________ ____________ Baldness Excess hair
Highest Educational Attainment: ___________________________ Head
Last year Of School: __________________________________________ Headache
Occupational History: ________________________________________ Dizziness Tenderness
Occupational Hazards: _______________________________________ Lightheadedness Trauma
Syncope

Page 2 of 7
Eyes Pallor
Pain Redness
Double vision Blurred vision Endocrine
Photalgia Lacrimation Polydipsia Polyphagia
Use of glass/lenses Heat/cold intolerance Excessive sweating
Grade: ________________________ Psychiatric
Started when: ________________ Nervousness Depression
Frequency of use: ____________ Anxiety Hallucinations
Ears
Hearing problem Earache IX. PHYSICAL EXAMINATION
Discharge (color/consistency): ____________
Itching A. General Survey
Mouth and Throat Mood: _____________________________________________________
Use of dentures Mouth sores Distress/Unusual Position: _____________________________
Bleeding gums Sore throat Cooperative / Non-cooperative: _______________________
Hoarseness Dysphagia Irritated / Agitated / Pleasant: ________________________
Toothache Coherent: ________________________________________________
Neck Oriented to time and space: ___________________________
Pain Stiffness Personal Hygiene: ______________________________________
Lump Level of Consciousness: ________________________________
Breast Apparent State of Health: ______________________________
Pain Discharge acutely ill/ chronically ill/ frail / fit and robust
Lumps .Periodic exam
Respiratory B. Anthropometric Measurement
Cough Sputum color/quantity): ____ Height: ____________________________________________
Hemoptysis Dyspnea Weight: ___________________________________________
Cardiovascular BMI:
Chest pain Palpitations Weight (kg) __________= ______________________
Orthopnea Edema Height (m2)
Cyanosis Paroxysnal Nocturnal Dyspnea Underweight (<18.5)
Easy Fatigability Normal (18.5-24.9)
Gastrointestinal Overweight (25-29.9)
Loss of appetite Nausea Obese I (30-34.9)
Vomiting Hematemesis Obese II (35-39.9)
Abdominal pain Dysphagia Obese III (>40)
Hematochezia Diarrhea
Hemorrhoids Constipation C. Vital Signs
Stool: ________________ Temperature: _______ Oral Axillary Rectal
Renal:_______________________________________________ Respiration: ________ Normal Labored
Dysuria Polyuria Pulse: _____________ Regular R. Irregular
Nocturia Gross Hematuria Irr. irregular
Incontinence Urinary Retention Blood Pressure: _____ Lying Sitting Standing
Urinary Urgency Tea-Colored Urine Left Arm: _____________
In Males: Right Arm: ___________
Reduced caliber of force of stream
Hesitancy D. Skin
Dribbling Color:
Genitalia normal
Pain Swelling increased pigmentation loss of pigmentation
Discharge (characteristics): ___________________ redness pallor
Ulcers Itching cyanosis jaundice
Peripheral Vascular Moisture:
Leg cramps Varicose veins dry moist/wet
Musculoskeletal oily
Muscle weakness Stiffness Temperature:
Backache Joint swelling generalized warmth/coolness
Muscle pain Joint pain local warmth/coolness
Neurologic Texture: rough/ smooth
Paralysis Numbness Mobility & Turgor:
Tremors Seizures inc/dec/normal mobility
Memory Loss inc/dec/normal turgor
Hematologic Lesions:
Location: _____________________________________________________
Easy bruising Bleeding

Page 3 of 7
 Distribution: _________________________________________________
Patterns/Shapes: ____________________________________________
Type: _________________________________________________________
Color: _________________________________________________________
E. Head
Trauma: ___________________________________________
Size: __________ Shape: ________________________
Tenderness: _______________________________________
Condition of hair and scalp: ______________________
Symmetry: _________________________________________
Masses: ___________________________________________
F. 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: _______________________________
G. Ears
Symmetry: _________________________________________
Swelling: _________________________________________
Redness: _________________________________________
Discharge: _______________________________________
Tenderness: ______________________________________
Hearing Impairments: ______________________________
Presence of Hearing Aid: ____________________________
Weber Test: ________________________________________
Rinne Test: (R) AC _______ (BC) _______
(L) AC _______ (BC) _______
H. Nose
Symmetry: _________________________________________
Frontal, Maxillary sinus tenderness: ____________
Obstruction: _______________________________________
Congestion: ________________________________________
Lesions: ___________________________________________
Exudates: __________________________________________
Inflammation: ______________________________________
I. Mouth & Throat
Lips:
Color: ____________ Moisture: __________
Lumps/ulcers/cracks/scales
Teeth/dentures: ____________________________________
Gums: ____________________________________________
Tongue:
Color: ___________ Texture: ___________
Deviation _______________________________
Pharynx: ___________________________________________
Lesions: __________ Erythema: __________
Exudates: _________ Tonsillar size: _________
Uvula: _______________________________________________
Tonsils: ______________________________________________
J. Neck
Symmetry: _________________________________________
Limitation of ROM: __________________________________
Tenderness: ________________________________________
JVP: ______________________________________________
Lymph nodes: ______________________________________
Size: _______________________________________
Mobility: ___________________________________
Tenderness: ________________________________
Borders: ___________________________________
Consistency: ________________________________
Thyroid Cartilage: _______ Cricoid cartilage: _______
Thyroid gland: ______________________________________
K. Chest and Lungs
1. Inspection
Comfort and Breathing Pattern: _______________________
Shape of the Chest: __________________________________
Chest Movement: ____________________________________
Use of Accessory Muscles of Breathing:
Deformities or Asymmetry
A/N Retraction of Interspaces on Inspiration
Retraction of the interspaces when breathing
Color of Patient (Lips and Nail Bed): ______________________
2. Palpation
Tender Areas: ________________________________________
Respiratory Expansion (10th rib): __________________________
Tactile Fremitus:
Increased Decreased Absent
3. Percussion
_________________________________________
4. Auscultation (Jamee)
________________________________________
Breath Sounds:_______________________________________________
Bronchophony Whispered Petoriloquy
Egophony
L. Heart
1. Inspection
Precordial bulge or heave: ____________________________
PMI: ______________________________________________
Page 4 of 7
2. Palpation
PMI: ______________________________________________
Thrill: _____________________________________________
Location: ___________________________________
Timing in Cardiac Cycle (S/D): _________________
Mode of Extension / Transmission: ______________
Friction Rub: ______________________________________
3. Percussion
Cardiac Borders
Right (cm) ICS/MSL Left (cm)
5th
4th
3rd
2nd
4. Auscultation
S1 (M-loud, T-split): __________________________________
S2 (A,P-loud, P-split I): ________________________________
S3: _______________________________________________
Murmurs/ Accessory Heart Sounds:
Location:_______________ Timing:______________
Quality:________________ Pitch:_______________
Intensity:_______________ Radiation:___________
M. 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:____________________________________
N. Abdomen
1.General
Inspection
Skin
Scars: ___________________________________________
Striae:___________________________________________
Dilated Veins: __________________________________
Discoloration: __________________________________
Umbilicus
Contour: _____________________________________
Location: _____________________________________
Contour of Abdomen
Flat/Rounded/Protuberant/Scaphoid
Bulges: _________________________________________
Symmetry: _____________________________________
Distance of umbilicus from xiphoid process: __________
Abdominal Girth:_________________________________________
Peristalsis: ________________________________________________
Pulsations: ________________________________________________
Auscultation
Bowel Sounds
Frequency:__________ Character:__________
Bruit:____________________________________________
Venous Hum:_____________________________________
Friction Rub:______________________________________
Percussion
Splenic Dullness:____________________________________
Other Areas of Dullness: ______________________________
Palpation
Light Palpation
Abdominal tenderness: ______________________________
Muscular resistance: _________________________________
Deep Palpation
Masses: ______________________________
Location: ______________________________
Size: ______________________________
Shape: ______________________________
Consistency: ______________________________
Tenderness: ______________________________
Pulsations: ______________________________
Mobility with Respiration or Examining Hand:
______________________________
2. Liver
Percussion
Liver Span: ___________________________
Normal: 6-12 cm in (R) MCL
Palpation
Tenderness: _______________________________
Distance of Liver Edge from R Costal Margin in Midclavicular
Line: _______________________________________
Normal liver edge: soft, sharp, regular, smooth surface
Hooking
3. Spleen
Percussion
Splenic Percussion Sign: +/-
Palpation
Tenderness: ______________________________________________
Splenic contour: __________________________________________
Distance between lowest point and L costal margin:
______________________________________________
4. Kidney (Joyce)
Palpation (L)
Palpable/Not Palpable
Size: ______________________________________________________
Contour: _________________________________________________
Tenderness: _____________________________________________
Palpation (R)
Palpable/Not Palpable
Size: ______________________________________________________
Contour: _________________________________________________
Tenderness: _____________________________________________
Percussion
Costovertebral Angle Tenderness/ Kidney Punch:
_________________
5. Special Tests
Page 5 of 7
 Rebound Tenderness: Rovsing’s / Blumberg Agnosia (Visual, tactile, auditory autotopagnosia,
Costovertebral Tenderness anosognosia)
Shifting Dullness Praxis (Ideomotor, Ideational)
Psoas Sign Perception (Delusion, Hallucination, Illusion,
Murphy’s Sign Astereognosis, Agraphestesia)
I. Follows Command
O. Peripheral Vessels Take this paper. Fold it in half.
Inspection Place it on the table
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
Grading of Pulses CN II
Brachial (Joyce): ___________________________
Visual acuity:_____________ Visual Field: ________________
Femoral (Cha): _____________________________
Fundoscopy: _______________________________________
Popliteal (James): __________________________
CN III, IV, VI
Dorsalies Pedis (Jamee): __________________
Tibialis Posterior (Monique):_____________ Size and Shape of Pupil: ______________________________
Special Tests Light Reaction Accommodation
Allen Test (Charmie): _____________________ EOM:
Trendelenburg Test (Jamie):_____________ Paresis Nystagmus
Saccades Oculomotor Ataxia
Diplopia Other: _____________________
P. Male Genitalia CN V
Penile Lesions:____________________________________ Ophthalmic Maxillary
Scrotal Swelling:___________________________________ Mandibular Corneal Reflex
Testicles Jaw Clench
Size:_________ Tenderness:________________ CN VII
Masses:___________________________________ Eyebrow Elevation Forehead Wrinkling
Varicocoele:_______________________________ Eye Closure Smiling
Hernia:__________________________________________ Cheek Puffing
Transillumination: ___________________________________ CN VIII
Hear finger rub or whispered voice
Q. Neurologic Exam Rinne:___________________ Weber: ___________________
Mental Status Examination CN IX, X
A. Awareness Palate and Uvula: ___________________________________
Orientation Gag Reflex
Name: Season Date Day Month Year CN XI
Name: Hospital Floor Town State Country Shoulder Shrug (against resistance)
Level of Consciousness: Head Rotation (against resistance)
B. Speech (Normal, dysphasia, dysarthria, dysphonia) CN XII (Tongue)
C. Language Atrophy Fasciculation
Name: Pencil Watch Position with protrusion:______________________________
Repeat: “ No ifs ands or buts” Strength:___________________________________________
D. General Knowledge
Knowledge of current events, vocabulary Motor Examination
(Historical events, 5 last presidents, 5 largest cities) Involuntary Movements
E. Memory Symmetry
Immediate, recent, remote
Atrophy
F. Registration (Retention and Recall)
Gait
Identify: Object 1 Object 2 Object 3
Spasticity
Attention and Calculation
Rigidity
(100-7…): 93 86 79 72 65
Flaccidity
Recall
Clonus
Recall: Object 1 Object 2 Object 3
Carpopedal Spasm
G. Reasoning
Judgment, Insight, Abstraction (interpretation of Tics
proverbs) Tremors
H. Object Recognition Athetosis

Page 6 of 7
 Others Babinski

Tone Sensory
Description: ________________________________________ Pin prick
Flaccidity Touch
Spasticity Two point discrimination
Sense of Position
Muscle Strength Vibratory Sense
(R) (L) Superficial sensation
Shoulder Flexion Deep Sensation
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

Page 7 of 7