Date______________________________________ Source of Referral____________________________

History taken by_____________________________ Informant___________________________________

% Reliability_________________________________

PATIENT HISTORY
IDENTIFYING DATA

Name____________________________________________Age____Sex: [M] [F] Civil Status: [Single] [Married] [Separated] [Widow]

Occupation___________________________________Nationality________________________Religion________________________

Date of Birth__________________________________Place of Birth_____________________________________________________

Present Address_______________________________________________________________________________________________

No. of Times Admitted to the Hospital______________Date of Admission________________________________________________

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

Onset of illness gradual/sudden, chronological sequence of symptoms, description of each symptom (P-precipitating /
aggravating / palliating; Q-quality / type / character; R-region / location / radiation; S-severity / intensity / progression; T-
temporality / onset / duration / frequency), consultation made and medications taken (name & dose / response to Tx)

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PAST MEDICAL HISTORY

1. Childhood diseases
__Mumps__Measles__Chickenpox__German Measles
2. Adult Past Illness
a. Medical (date, name of hospital, described symptoms or diagnosis and result of Tx)
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b. Surgical (type, date, results and complications)
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c. Gynecologic
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 d. Psychiatric
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e. Accidents / Injuries
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f. Blood transfusions
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g. Allergies
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3. Immunizations received
__MMR __BCG__Polio__HiB__Hepa A__Hepa B__DPT__Influenza__HPV__Pneumonia Others______________

FAMILY MEDICAL HISTORY

Health status of parents and siblings (age and current health status, illness; if deceased age at time and cause of death)

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Disease/s with familial tendency (Cancers, HPN, DM, Heart Disease, Alcoholism, Psychiatric)

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Any member of the family with similar symptoms____________________________________________________________________

PERSONAL AND SOCIAL HISTORY

Educational Attainment_____________________________Occupational History___________________________________________

Marital Status_____________________________________Others______________________________________________________

Habits (sleep pattern, diet, coffee, alcohol intake, smoking, use of drugs prescribed/prohibited/self-medication/
supplements; hobbies, exercise)

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MENSTRUAL AND OBSTETRIC HISTORY

Age at menarche_____Interval________________________Duration__________________Amount of flow_____________________

PMS_____________________LMP______________________PMP____________________(G)_______(P)________; Live births_____

Manner of delivery (NSD, CS, Forceps extraction)____________________________________________________________________

Place of delivery_______________________________________________________________________________________________

Postpartum Complications______________________________________________________________________________________
REVIEW OF SYSTEMS

Constitutional Symptoms Respiratory System

__weight gain/loss (amount, period, time)________; __dyspnea (DOB/SOB); __chest pain; __cough; __sputum
__weakness; __fatigue; __fever; __chills; __loss of appetite production; __hemoptysis; __wheezing; __Hx of asthma

Skin Cardiovascular System

__itchiness; __excessive dryness/sweating; __change in __substernal pain; __palpitations; __dyspnea (DOB/SOB);

color (cyanosis, pallor, jaundice, erythema) __orthopnea (#of pillows)__; __paroxysmal nocturnal
dyspnea __easy fatigability
Head
Gastrointestinal
__headache; __dizziness/vertigo
__abdominal pain; __nausea; __vomiting; __dysphagia;
Eyes __diarrhea; __constipation; __hematemesis; __melena;
__hematochezia; __regurgitation
__pain; __blurring of vision; __double vision; __lacrimation;
__photophobia; __use of eyeglasses (grade)_______ Genitourinary Tract
Ears __dysuria; __urinary frequency; __urgency; __hesitancy;
__polyuria; __hematuria; __incontinence; __genital
__earache; __deafness; __tinnitus; __ear discharge pruritus; __urethral discharge
(quality)________________
Extremities
Nose and Sinuses
__edema (location)____________; __swelling of joints;
__changes in smell; __nose bleeding; __nasal __stiffness; __numbness; __intermitted claudication;
obstruction; __nasal dischanrge; __pain around paranasal __limitation of movement
sinus
Nervous System
Mouth and Throat
__headache; __vertigo; __syncope; __loss of consciousness;
__toothache; __gum bleeding; __disturbance in taste; __sore
__weakness; __paralysis; __numbness; __paresthesia;
throat; __hoarseness
__speech disorder; __loss of memory; __confusion
Neck
Hematopoietic System
__pain; __limitations of movement; __presence of mass
__bleeding tendencies; __pallor; __easy bruising; __Hx of
Breast transfusion reactions (describe) ____________________

Endocrine System
__pain; __lumps; __nipple discharge
(quality)__________________
__heat/cold intolerance; __excessive weight gain/loss;
__polyuria; __polydipsia
PHYSICAL ASSESSMENT:

HEAD
CRANIUM Normal Abnormal
Hair quantity
Color __ Black __ Brown __ white
Distribution __ Hypertrichosis
__ Hypotrichosis
__ Alopecia
__ Trichotillomania
__ Tinea capitis

Size __ Proportional to the body __ Macrocephalic

__ Microcephalic
__ Hydrocephalus

Shape __ Normocephalic __ Dolichocephalic

__ Bradycephalic
Symmetry __ Symmetric __ Not symmetric
Deformities
Swelling
Tenderness

Temporal arteries __ Not Visible __ Visible

__ Palpable
FACE
Symmetry __ Symmetrical __ Not symmetrical

Facie __ Normal facie __ abnormal facie (e.g. Bells Palsy)

Lesions
Involuntary movements __ Without involuntary movements __ With involuntary movements

EXAMINATION OF THE EYES

Eye Structures Normal Deviations
1. eyebrow Hair evenly distributed Loss of hair
Skin intact Scaling, flakiness
Symmetrically aligned Unequal alignment , movement
Equal movement Others:____________________
2. eyelashes equally distributed turned inward
curled outward Others:__________________
no matting
3. Eyelids skin intact redness
no discharge swelling
no discoloration flaking
close symmetrically crusting
bilateral blinking plaques
when lids open, no visible sclera above discharge
corneas, and upper and lower borders of nodule
cornea are slightly covered lesions: _________
negative lid lag test lids close asymmetrically, incompletely, or painfully
rapid, monocular, absent or infrequent blinking
ptosis
ectropioin or entropion
rim of sclera visible between lid and iris
(+) lid lag test
Others:____________________
4. Eyeballs Normal set of eye balls Exopthalmos
 no exopthalmos or enopthalmos Enopthalmos
5. Bulbar Transparent; some capillaries are evident Icteric sclera
conjunctiva White sclera Pale sclera
Reddened sclera
Lesions or nodules
Others:____________________
6. Palpebral Shiny Pale
conjunctiva Smooth Extremely red
Pink or red Nodules or other lesions ___________
Others:____________________
7. Lacrimal gland No edema Swelling
No tenderness Tenderness
Others:____________________
8. Lacrimal sac and No edema Increased tearing
nasolacrimal No tearing Others:____________________
duct
9. Cornea and iris transparent, shiny, smooth opaque
iris are visible, flat, brown color surface not smooth
scars, abrasions and ulcers
Others:____________________
10. Corneal Blinks when cornea is touched with corner One or both eye failed to respond: L or R
sensitivity reflex of cotton Others:____________________
(CN 5)
11. pupil black cloudiness
equal in size (3-7mm) mydriasis
round, smooth border miosis
iris flat and round anisocoria
bulging of iris toward cornea
Others:____________________
12. Pupils direct Illuminated pupil constricts (direct Neither pupil constricts
and consensual response) Unequal responses
reaction Non-illuminated pupil constricts Others:____________________
(consensual response)
13. Pupils reaction Constrict when looking at near, dilate at One or both pupils fail to constrict, dilate or converge
to far, converge when near object is moved Others:____________________
accommodation toward nose (PERRLA)
14. Lens Transparent Opaque
Fundoscopic examination reveals positive (-) ROR
red orange reflex, presence of retinal Bulging optic disc
vessels and normal optic disc. Specify abnormality in retinal vessels:_________
Others:____________________

Ear
External Ear: Normal Abnormal
The Auricle
Size __normal in size __size not proportional (too big, too small)

__not symmetrical: Specify_________

Symmetry __symmetrical
__(+) deformity: Specify_________
Deformity __ no deformity
__(+)lump/s:
Lumps __no lumps Size______________
Location________________

__(+)lesion/s:
Skin lesion __no lesion Size______________
Location________________

__(+) pain
__no pain
Ear ache
 __(+) discharge:
Discharge __no discharge Consistency____________
Color_______________

__(+)inflammation
Inflammation __no inflammation
__(+)tenderness
Tenderness __ no ternderness

Otoscopic Exam
Patency __ Patent __ Impacted cerumen
__foreign body
__others: Specify____________

Discharge __ (-)discharge __(+)discharge

Color________________
Consistency______________

Wall of ear canal __(-)swelling __ (+)swelling

__(+)redness
Tympanic membrane __pearly white __hyperemic (meringitis)
__pinkish grey __others: Specify_____________

__intact __perforated

__flat __bulging: (fluid in the middle ear)

__retracted: (pulled upward due to a block in
the Eustachian tube)

__(+) cone of light __(-) cone of light

__malleus visible __not visible

Nose, Paranasal Sinuses

Area to check normal findings abnormal findings comments

Nose symmetrical no flaring asymmetrical tender nose tip
nose tip not tender flaring of ala nasi
Nasal cavity(vestibule), cavity: patent pink cavity:
septum & turbinates obstructed polyp ulcer
mucosa: pale red bluish
septum: pink midline septum:
deviated to the _______
perforated epistaxis
turbinates:
turbinates: pink flat congested discharge - _______
pale red bluish
Paranasal sinuses Frontal Frontal
(Palpate & non-tender local tenderness (R/ L/both)
Transillumination) (+) transillumination test absence of glow (R/ L/both)

Maxillary Maxillary
non-tender local tenderness (R/ L/both)
(+) transillumination test absence of glow (R/ L/both)
Oral cavity (by: BAJAMONDE)

Area to check normal findings abnormal findings comments

Lips pink symmetrical moist deformed pale red bluish dry edema
no lesions scaly fissuring crust ulcer
Gingiva pink smooth moist swelling ulcer tumor pale red bluish
 no swelling no lesions
Mucosa, hard and soft pink smooth moist mucosa or palate (specify):
palate no swelling no lesions canker sore tumor dry swollen
pale red bluish icteric
spots or patch (yellow/ white/ petechial)
Teeth complete set (32) extracted caries fillings [specify laterality]
st nd st nd rd
no discoloration, caries fillings, (C.i./L.i./can./1 PM/2 PM/1 M/2 M/3 M)
dentures discoloration (black/ yellow/ brown/ grey-blue)
good oral hygiene dentures halitosis
attrition [long slim tooth] wide -spaced
eroded notched biting surface
Tongue Dorsum: asymmetric geographic
normal size symmetrical hairy [brown to black elongated papilla]
pink rough papilla white-coated[candidiasis] canker sore
midline mobile fissured/scrotal smooth/atrophic
no tremors no lesions white patches [leukoplakia] varicose veins
Mouth Floor/undersurface
pink midline frenulum
Throat/Pharynx (Uvula, uvula: midline no exudates tonsillitis enlarged tonsils[not swollen]
Tonsils, Pharyngeal no lesions exudates (yellow/white/blood/grey)
wall) tonsils: not enlarged/swollen pharyngitis [all are swollen]
no exudates no lesions ulcer tumor
Pharyngeal wall: pink no exudates
no lesions

EXAMINATION OF THE NECK (by: BACAYO)

NORMAL ABNORMAL

INSPECTION
Normal in size
Symmetrical NOT symmetrical
No visible mass (+) visible mass
No deformity (+) deformity
No swelling (+) swelling
Normal Range of Motion
PALPATION
TRACHEA
Midline Deviates to the R or L
LYMPH NODES
NOT PALPABLE PALPABLE (size,shape,surface/texture, delimitation, mobility,
cosistency,tenderness)
Preauricular Preauricular
Posterior Auricular Posterior Auricular
Occipital Occipital
Tonsillar Tonsillar
Submandibular Submandibular
Submental Submental
Superficial Cervical Superficial Cervical
Posterior Cervical Chain Posterior Cervical Chain
Deep Cervical Chain Deep Cervical Chain
Supraclavicular Supraclavicular
THYROID GLAND
NOT visible visible
NOT palpable palpable
o size
o shape
o symmetry
o consistency
o presence of nodule
 o tenderness
o bruit

Examination of the Thorax and Lungs (by: CABAGYO)

AREA NORMAL ABNORMAL COMMENTS

INSPECTION
Skin
Color Brown
Lesion No lesions
Blood vessels No dilated blood vessels
Bony Thorax
Shape Elliptical AP diameter: ____________
Symmetry Symmetrical Assymetrical
Deformity Barrel chest
Traumatic Flail Chest
Funnel Chest (Pectus Excavatum)
Pigeon Chest (Pectus Carinatum)
Thoracic Kyphoscoliosis
Muscle Development under developed
fairly developed
highly developed
Respiration
Respiratory rate 14-20 cpm RR:_________________
Rhythm and depth inspiration longer than tachypnea
expiration hyperpnea, hyperventilation
Bradypnea
Cheyne-stokes
biots
sighing respiration
obstructive respiration

use of accessory muscles

Respiratory effort effortless
abdonimal paradox
Lung expansion symmetry of expansion
PALPATION
Chest expansion symmetrical assymetrical
Tactile fremitus equal increased (consolidation)
decreased (pneumothorax,
atelectasis)
PERCUSSION
resonant flat (large pleural effusion)
dull (lobar pneumonia)
resonant (simple chronic
bronchitis)
hyperresonant (emphysema,
pneumothorax, severe
bronchial asthma)
tympanitic (large pneumothorax)
AUSCULTATION
Breath sound vesicular crackles
wheezes and rhonchi
stridor
pleural rub
mediastinal crunch
Vocal fremitus (-) bronchophony (+) bronchophony
(-) whisper pectoriloquiy (+) whisper pectoriloquiy
(-) egophony (+) egophony

EXAMINATION OF THE HEART: (by: CABREDO)

JVP Normal abnormal
CVP (<10) Normal abnormal
CAROTID PULSATION
Amplitude Strong weak
Rhythm Regular irregular
Equality Equal unequal
consistency of wall Soft rigid

PMI
location: (___________) Normal abnormal
size (<2.5cm) normal abnormal
Amplitude (gentle tap) normal abnormal
Rhythm regular irregular

PRECORDIUM
Adynamic Dynamic Hyperdynamic
Thrust/heave/lift absent present
location:
timing:
Thrills absent present
location:
timing:

CARDIAC RATE:
regular irregular
S1(apex) soft normal accentuated
S2(base) soft normal accentuated
splitting S1/S2 absent present
S3 absent present
S4 absent present

MURMUR: absent present

Type:
location
radiation
timing
intensity
quality
pitch
shape