DATE Surgical

GENERAL DATA (w/ dates, indications and

Name type of operation)
Age/Sex
Birthday
Address
Religion Obstetrics/Gynecology

Marital Status
Occupation Menarche

Educational Attainment Menopause

Referral Psychiatric

Admission ___ 1st ___ 2nd ___ 3rd IMMUNIZATIONS

Date of admission: SCREENING TESTS

SOURCE OF HISTORY Allergies

CHIEF COMPLAINT
FAMILY HISTORY

HISTORY OF PRESENT ILLNESS

Father

Mother

Husband/Wife

Siblings

PAST HISTORY
CHILDHOOD ILLNESS Children
Mumps Whooping cough/Tetanus
Chicken pox Rheumatic fever
measles Scarlet fever PERSONAL AND SOCIAL HISTORY

rubella polio Medications

Varicella Dengue fever

ADULT ILLNESS
Medical (w/ dates of onset) Tobacco

Diabetes, hypertension,
hepatitis, asthma, kidney dse, Alcohol
stroke, arthritis, heart dse, Drug
blood disorder, epilepsy, mental
disorder
Exercise/Diet
 __pain with defecation __rectal bleeding,
REVIEW OF SYSTEMS __black tarry stools, __hemorrhoids,
General: __constipation, __diarrhea,
__Recent weight change __Weakness __abdominal pain, __excessive belching,
__fatigue __fever __abdominal distension __indigestion

Skin: Peripheral Vascular:

__Rashes, __lumps, __Intermittent claudication, __leg cramps,
__sores, __itching, __varicose veins, __past clots in veins,
__Dryne ss, __changes in color, __swelling in calves, legs or feet, __color change in
__Changes in hair or nails, __changes in size/color fingertips or toes during cold weather,
of moles __swelling with redness or tenderness

HEENT Urinary:
Head: __Frequency of urination, __polyuria,
__Headache, __head injury, __nocturia, __urgency,
__dizziness, __lightheadedness __burning or pain during urination, __hematuria,
__ flank pain __suprapubic pain,
Eyes: __incontinence, __in males reduced
__Blurry Vision, __glasses/contact lens, force of the urinary stream,
__pain, __redness, __hesitancy, __dribbling
__tearing, __double vision,
__spots, __specks, Genital:
__flashing lights, __glaucoma, __Pain, __swelling __discharge
__cataract __trauma
Ears: Musculoskeletal:
__Hearing, __tinnitus, __Muscle or joint pain, __stiffness
__earaches, __ infection, __back ache __limitation of motion,
__discharge __neck pain
Nose:
__Colds, __discharge, Psychiatric:
__itching, __nose bleeds, __Nervousness, __anxiety
__abnormal olfaction __ depression __memory change
Throat:
__Toothache, __gums bleeding, Neurologic:
__dentures, __sore tongue, __dizziness, __vertigo,
__dry mouth, __sore throat, __fainting, __blackouts
__hoarseness __dental carries __paralysis __numbness
Neck: __tingling, __tremors
__Swollen glands, __goiter, __seizures
__lumps, __pain,
__stiff neck Hematologic:
__Anemia, __easy bruising or
Breasts: bleeding,
__Lumps, __pain, __ past transfusion __pica
__discomfort, __nipple discharge,
__self-exam Endocrine:
__heat or cold intolerance, __ excessive sweating,
Respiratory: __excessive thirst or hunger __ polyuria
__Cough, __sputum(color, quantity), __thyroid problems
__hemoptysis, __dyspnea,
__wheezing, __asthma,

Cardiovascular: Last BP: ________mmHg

__ chest pain __palpitations,
__orthopnea, __hypertension
__syncope __edema

Gastrointestinal:
__Trouble swallowing, __heartburn
__nausea __appetite
__Bowel movements, __stool color and size, ,
PHYSICAL EXAMINATION
VITAL SIGNS Nose: mucosa : ___________________________
Septum: ___________________________
Mucus discharge: ___________________________
BP= ________ mmHg ___L ___R ___Sitting ___lying Mouth: lips: ___pallor ___cyanosis
PR= ________ bpm ___regular ___irregular ___dry/cracked ___lesions
Gums: ___pinkish ___pallor
RR= ________ /min ___regular ___irregular
___bleeding ___tenderness
Temperature = ________C O2Sat= ________% Mucosa: ___________________________
Height: ________ Weight: ________ Tongue: ___________________________
Teeth: ___________________________
BMI: ________
Tonsils: ___________________________
General Survey
___awake, alert,responsive ___stuporous Neck: carotid artery: ___ Thrills ___bruits
___lethargic ___comatose Trachea: ___________________________
___Obtunded Lumps/Lymph Nodes __________________________
___cardiorespiratory distress ___anxiety
___pain ___depression
Breasts: ___ symmetric ___ tenderness
___alert,attentive to questions ___recumbent
___makes eye contact ___ masses
___appears dull, drowsy , stares into space
___confused ___angry THORAX AND LUNGS:
___impatient ___restless ___Deformity: ___barrel ___funnel
Skin: ___pigeon ___kyphoscoliosis
Color: ___ redness ___ pallor Signs of distress: ___alar flaring ___purse lip breathing
___ cyanosis ___ jaundice ___intercostal retractions
Texture: ___rough/ dry ___smooth ___use of accessory muscles
Moisture: ___dry ___wet/clammy ___ oily Chest expansion: ___symmetrical ___Lag at R/L
Turgor: ___ Good ___Fair ___Poor Palpation: ___tenderness ___masses
Temperature: ___symmetrical ___nonsymmetrical Tactile fremitus: ___ symmetrical ___decreased at____
___ rashes (describe) Note on percussion: ___flat ___hyperresonant
___ lesions ___dull ___tympanitic
___ abrasions ___resonant
Breath sounds: ___vesicular ___bronchial
___bronchovesicular ___tracheal
Nails: ___oil spots ___lesions ___pitting Adventitious breath sounds:
Hair: ___coarse ___dry ___smooth & soft ___crackles ___ stridor
alopecia: ___diffuse ___patchy ___total ___wheezes ___pleural friction rub
___rhonchi ___mediastinal crunch
HEENT:
Head: ___normocepahlic ___brachycephalic CARDIOVASCULAR:
___ dolichocephalic PMI at: ___________________________
Abrasions: (measure) Heart sounds: ___distinct ___faint
S1___S2 at the base
S1___S2 at the apex
Eyes: periorbital region: ___swelling ___sunken Extra heart sounds: ___S3 ___S4
visual field ___________________________ ___murmurs (grade: ___)
Conjunctiva :___________________________
Pupils: ___________________________ ABDOMINAL:
Extraocular movements: _______________________ Skin: ___ scars ___striae
Visual Acuity: R 20/_____ L 20/_____ ___dilated veins ___rashes and lesions
Ears: ___ deformity ___ obstruction Umbilicus: ___ sunken ___bulging
Rinne: R: ___ac>bc ___bc>ac ___inflammation
L: ___ac>bc ___bc>ac Contour: ___flat ___ globular
Weber: ___Right ___left ___ protuberant ___flabby
Bowel Sounds: ______/min(normal 4-6/min) ___borborygmi ___pain: _________________________________
___increased ___bruits ___tenderness: ______________________________
___decreased ___friction rub
___absent ___venous hum Genitals: ___ lesion ___ swelling
Percussion: ___ hypertympanitic ___tympanitic ___ discharge ___ pain
___dullness at _____________________
(4-8 substernal, 6-12 midclavicular)
NEUROLOGIC:
___shifting dullness
Mental Status:
Tenderness on percussion: ___yes ___no
Cranial Nerves:
Tenderness on palpation: ___yes ___no
I odor
II visual fields
PERIPHERAL VASCULAR:
III, IV, VI eye coordination, pupils
Capillary refill time: ______secs (normal 2 secs)
V facial sensation
___edema of extremities: ___bilateral ___unilateral
VII symmetry, ability to close eyes
___pitting ___nonpitting
VIII hear finger rub
Peripheral pulses: ___ symmetrical ___regular
IX, X able to swallow
___asymmetrical ___irregular
XI shrug the shoulders
___weak ___strong
XII tongue deviation or atrophy
___faint ___bounding
___absent ___grade: ___

EXTREMITIES:
True leg length: Right______ Left ______
Apparent LL: Right______ Left ______
___tenderness ___deformity
RUE LUE RLE LLE

MUSCULOSKELETAL:
ROM:
Cervial: ___ flexion 0-45
___ rotation 0-60
Thoracolumbar: ___flexion 0-80
___rotation 0-35
Shoulder: ___flexion 0-180
___abduction 0-180
___ medial rotation 0-70
Elbow: ___flexion 0-150
___supination 0-80
Wrist: ___flexion 0-80
___radial deviation 0-20
Thumb: ___ CMC flexion 0-15
___CMC Abduction 0-70
___IP Flexion 0-80
2nd-5th: ___MCP flexion 0-90
___MCP hyperextension 0-45 ___PIP flexion 0-100
___DIP flexion 0-90
Hip: ___ flexion 0-120
___Adduction 0-30
___ lat rotation 0-45
Knee: ___ flexion 0-150
Ankle: ___ Dorsiflexion 0-20
___inversion 0-35
MOTOR 5/5
SENSORY
___extension 0-45
___lateral flexion 0-45
___extension 0-25
___lateral flexion 0-45
___ extension 0-60
___ lat rotation 0-90
___ pronation 0-80
___ extension 0-70
___ulnar deviation 0-30
___ CMC extension 0-20
___MCP flexion 0-50
___ MCP Abduction0-45
___DIP hyperextension 0-10
___extension 0-30
___Abduction 0-45
___ med rotation 0-45
___ extension 0-10
___Pantarflexion 0-50
___ eversion 0-15