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General data

Date: ________________
Time: _______________

Name ________________________________________________________________________
Age: ____ Gender: M F Religion: _________________Status: M S W
Sep
Place of Birth: __________________________ Occupation: ____________________________
Address:______________________________________________________________________
Source of Referral: ______________
Informant: _____________________Reliability___________
Date admitted:______________________________________
Chief Complaint: _____________________________________________________
History of Present Illness: (Onset, Precipitating Fx, Qual, Quan, Radn, relieveving Fx, Risk
Fx, Setting, Timing)
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Past Medical History: (Childhood illnesses, Medical, surgical, OB-GYNE History, Accidents,
Injuries, Transfusions)

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Family History: (Age, health status and cause of death of family members)
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- Indicates patient
- Deceased male
- Deceased female
-Living male
- Living female
Personal and Social History: (Occupation, Education, Home situation, Daily life, Leisure
activities, beliefs)
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REVIEW OF SYSTEMS

General: usual weight________ recent weight change________(-) fatigue, (-) fever

(-) sleep disturbances
Skin: (- ) rashes; ( - ) hives, (- ) color change ( - ) easy bruising or bleeding, (-) lumps, (-)
sores, (-) itching, (-) dryness, (-) changes in hair or nails
Head: (- ) headaches; (- ) injuries
Eyes: ( - ) visual changes; ( - ) crossed; ( - ) discharge; ( - ) redness; (- ) puffiness
(-) glasses, or contact lenses, last eye examination, (-)pain, (- ) injuries
(-)excessive tearing, (-)double vision,(-) spots, (-)specks , (-) flashing light, (-) glaucoma,
(-)cataract
Ears: Hearing acuity, (-) tinnitus (-) vertigo, (- ) difficulty in hearing; (- ) pain; (- ) discharge
(- ) ear infxns

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Nose and sinuses: (- ) discharge watery or purulent, (-) frequent colds, (-) nasal stuffiness
( - ) difficulty in breathing thru the nose, (-) itching, (-) hay fever, (-) sinus touble
( -) epistaxis
Mouth and throat: ( - ) sore throat or tongue; (- ) difficulty in swallowing;
( - ) dental defects, (-) bleeding gums, (-) Hoarseness
Neck: ( - ) swollen glands, masses; (- ) stiffness; ( - ) symmetric, (-) pain
Breasts: ( - ) lumps; (- ) pain; ( - ) discharge, self examination
Lungs: ( - ) shortness of breath; ( - ) cough ( - ) hoarseness; (- ) wheezing; ( - ) hemoptysis; (- )
chest pain, (-) sputum: color______, hemoptysis, (-) astma, (-) bronchitis, (-)
emphysema, (-) pneumonia, (-) tuberculosis, (-) pleurisy, last chest x-ray.
Heart: (- ) cyanosis; ( - ) edema, (-) heart failure, (-) high blood pressure, (-) rheumatic fever, (-)
murmur, (-) chest pain or discomfort, (-) palpitations, (-) dyspnea, (-) orthopnea, (-) PND
GIT: (-) trouble in swallowing, (-) heartburn (-) nausea; (-) vomiting (-) diarrhea
(-) constipation, (-) loss of appetite, (-) vomiting of blood, (-) indigestion, (-) Hemorrhoids
(-) change in bowel habits, (-) rectal bleeding or black tarry stools,
(- ) abdominal pain; ( - ) jaundice, (-) liver trouble, (-) gallbladder trouble, (-) hepatitis
GUT: ( - ) dysuria; ( - ) hematuria; ( - ) frequency; ( - ) oliguria; ( - ) enuresis;
( - ) discharge, (-) polyuria, (-) nocturia, (-) urgency, (-) reduced caliber of the urinary
stream (-) reduced force of the urinary stream, (-) hesitancy, (-) incontinence
(-) urinary infections, (-) stones
Genital, Male: (-) hernia, (-) penile discharge (-) sores, (-) testicular pain
(-) testicular masses, (-) sexually transmitted diseases, (-) exposure to HIV
infection
Genital, Female: M_____ I________ D ________ A__________S___________
Peripheral Vascular: (-) intermittent claudication, (-) Leg cramps, (-) Varicose veins
(-) clots in the veins,
Extremities: ( - ) weakness; (- ) deformities; ( -) diff in movement; ( - ) joint pains;
( - ) swelling; ( - ) cramps
Neurologic: ( - ) headaches; ( -) fainting; ( - ) dizziness; (- ) incoordination; (- ) seizures
( - ) tremors, (-) involuntary movements, (-) tingling sensation, (-) weakness, (-)
paralysis, (-) numbness, (-) attention span.

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Hematologic: ( - ) anemia, ( - ) easy bruising or bleeding, ( - ) past transfusion and possible
reaction..
Endocrine: ( -) thyroid trouble, ( -) heat intolerance (-)cold intolerance, ( -) excessive sweating,
( -) diabetes, ( -) excessive thirst (-) excessive hunger, ( -) polyuria.
Psychiatric: ( -) nervousness, ( -) tension, ( -) mood including depression
( -) suicidal ideation, ( -) memory loss
PHYSICAL EXAMINATION:
Vital Signs: BP:

GS:

PR:

RR:

Temp

Skin:
HEENT: _______ palpebral conjunctiva, _________sclera,
C/L: __________chest expansion, (-) retractions
Heart: ________precordium, _______rythm, (-) murmur
Abdomen_________, _________bowel sounds, ________, (-) tenderness on palpation
(-) mass palpated
DRE
Ext:
Genitalia:
Neuro:
MMSE:
GCS:
Cranial Nerves:
CN I:
CN II and III:
III, IV VI:
V:
VII:
VIII:
IX. X:
XI:
XII:

01234-

Motor:

5-

Cerebellars:

fatique.

Deep tendon reflexes:

Biceps

Triceps Sup

Rt
Lt
( ) Babinsky reflex
Sensory:
Pain
Temperature
Ligth touch
Vibration
Position
Stereognosis
Number identification
Two point discrimination
Point localization

No muscular contraction detected

A barely detectable flicker or trace of contraction
Active movement of the body with gravity eliminated
Active movement against gravity
Active movement against gravity and some resistance
Active movement against full resistance without evident

Abd

Knee

Ankle

Pl

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Extinction
Signs of meningeal irritation:
Gait and stance

Ocular Examination Findings

V.A. OD = NLP
OS= (+) HM
IOP : OU = 14 mmHg
Motility: OU = full & intact EOMs
Pupils: OS = 2-3 mm ERTOL
Biomicroscopy: OS = Cornea is clear; AC is formed; lens: (+) opacity, 12 diopter
Funduscopy: OU: cannot be assessed
LAI: patent; (-) discharge
Color perception, OS: good
Light projection, OS: good
Biometry: +20 diopter
IMPRESSION: CATARCT SENILE, MATURE, OS. BLIND EYE OD
PLAN:ECCE w/ PCIOL, OS, under Local (Retrobulbar) Anesthesia w/ a lens power of +12.0