HISTORY Present Illness: __Dizziness: __Night Sweats

Date and Time of History: Health Maintenance Information/ Past History: __Fatigue: __Others:
Date and Time of Admission: Current Medications:
Name: Allergies: Skin:
Address: Childhood Illnesses: __Rashes: __Dryness:
Birthday: Adult Illnesses: __Lumps: __Color Change:
Birth place: Operation: (dates) __Sores: __Changes in Hair or Nails:
Age: Other Hospitalization: (dates) __Moles: __Skin Disorder/CA:
Gender: Current Health Status: __Itching: __Others
Marital Status: __Tobacco:
Religion: __Alcohol, Drugs & Related Substances: Head:
Occupation: __Exercise & Diet: __Headache: __Head Injury
Handedness: Immunizations: __Dizziness/ Lightheadedness:
Source of History or Referral: __Screening Tests:
Reliability: Eyes:
Chief Complaints: Safety Measures: __Vision: __Double Vision:
______________________________________________ Family History: (Pedigree with age & cause of death) __Glasses or CL: __Blurred Vision:
______________________________________________ __Diabetes: __Last Examination: __Spots:
______________________________________________ __Heart Disease: __Pain: __Specks:
__Hypercholesterolemia: __Redness: __Flashing Lights
History of Present Illness/Active Problem: __High BP: __Excessive Tearing: __Glaucoma:
O:____________________________________________ __Stroke: __Cataracts __Others:
______________________________________________ __Kidney Disease:
L:____________________________________________ __TB: Ears:
______________________________________________ __CA: __Hearing: __Earaches:
D:____________________________________________ __Arthritis: __Tinnitus: __Infection:
______________________________________________ __Anemia: __Vertigo: __Discharge
C:____________________________________________ __Allergies:
______________________________________________ __Asthma: Nose & Sinuses:
A:____________________________________________ __Headaches: __Frequent Cold: __Itching:
______________________________________________ __Epilepsy: __Nasal Stuffiness: __Nosebleeds:
R:____________________________________________ __Mental Illness: __Discharge: __Sinus Problems:
______________________________________________ __Alcoholism: __Others:
T:____________________________________________ __Drug Addiction:
______________________________________________ __Death of Immediate Family Member: (if any) Mouth & Throat:
S:____________________________________________ Age & Cause: __Teeth & Gums: __Dry Mouth:
__Dentures (if any): __Sore Throat (ƒ):
Past History: Personal & Social History: __Hoarseness: __Others:
Occupation & Education: Last Dental Examination:
Childhood Illnesses: Home Situation & Significant Others:
Neck:
Adult Illnesses: Daily Life: __Lumps: __Pain:
Medical: __Goiter: __Stiffness:
Surgical: Important Experiences: __Others:
Psychiatric:
Leisure Activities/Hobbies: Breast:
Health Maintenance: Religious Affiliation & Beliefs: __Lumps: __Nipple Discharge:
Immunizations: __Pain or Discomfort: __Others:
Screening Tests: Review of Systems: Self-Examination Practices:
Medications: General:
__Weight Change: __Fever/Chills:

1
Respiratory: __Excessive sweating: __Diabetes:
__Cough: __Bronchitis: __Exposure to HIV Infection: __Excessive thirst or hunger: __Polyuria:
__Sputum (c, qty): __Emphysema:
__Hemoptysis: __Pneumonia: Female: Psychiatric:
__Dyspnea: __TB: __Age at Menarche: __Nervousness: __Tension:
__Wheezing: __Pleurisy: __Regularity: __Mood Disorder: __Substance abuse:
__Asthma: __Others: Frequency & Duration of Periods:
Last Chest X-ray: Amount of Bleeding: PHYSICAL EXAMINATION:
Bleeding (amount, between periods or after intercourse, GENERAL:
Cardiac: last menstrual period): General appearance:
__Heart Trouble: __Palpitations: __Dysmenorrhea, Premenstrual Tension: Temperature (oral/rectal):
__High BP: __Dyspnea: __Menopause (age, symptoms, postmenopausal Respiratory:
__Rheumatic Fever: __Orthopnea: bleeding): a. rate:_______/min
__Heart Murmurs: __PND: __Discharge: __Itching: b. rhythm: __________
__Chest Pain/Discomfort: __Edema: __Sores: __Lumps: Blood pressure: __________mmHg
Past ECG or other test results: __STDs and Treatment: If abnormal:
__# of Pregnancies: __# of Deliveries: a. Lying: __________mmHg
Gastrointestinal: __# of Abortions (spontaneous & Induced): b. Sitting: __________mmHg
__Trouble Swallowing: __Heartburn: __Complications of Pregnancy: c. Standing: __________mmHg
__Appetite: __Nausea: __Birth Control Methods: RUA:__________; LUA:__________
__Vomiting: __Regurgitation: __Sexual preference, interest, function, satisfaction: RLL:__________; LLL:__________
__Vomiting of Blood: __Indigestion: __Problems (including dyspareunia): Body size:
__Frequency of Bowel Movement: __Exposture to HIV infection: Height: __________
__Color & Size of Stools: Weight: __________
__Change in Bowel Habits: Peripheral Vascular: a. ideal body weight:
__Rectal Bleeding or Black Tarry Stools: __Intermittent Claudication: __Leg Cramps: b. % of ideal body weight:
__Hemorrhoids: __Constipation: __Varicose Veins: __Past Clots in Veins: Body habitus:
__Diarrhea: __Abdominal Pain: Hair:
__Food Intolerance: Skin:
__Excessive Belching or Passing of Gas: Musculoskeletal: (describe location & symptoms) Nails:
__Jaundice: __Hepatitis __Muscle or Joint Pains: Other:
__Liver or Gallbladder Trouble: __Stiffness:
__Others: __Arthritis: Head, Ears, Nose:
__Gout: Cranial/orbital bruit:
Urinary: __Backache: Pinnae/canals/drums:
__Frequency: __Hesitancy: Nose:
__Polyuria: __Dribbling: Neurologic: Other:
__Nocturia: __Incontinence: __Fainting: __Blackouts:
__Burning or Pain: __UTI: __Seizures: __Weakness: Eyes:
__Hematuria: __Stones: __Paralysis: __Stroke: External eyes:
__Urgency: __Others: __Sleep Disorder: __Others: Fundi:
__Numbness or Loss of Sensation: Pupil:
Genital: __Tingling of “pins & needles”: Other:
Male: __Tremor or other involuntary movements:
__Hernias: Oral Cavity:
__Discharge From or Sores on the Penis: Hematologic: Teeth/gums/oral mucosa:
__Testicular Pain or Masses: __Anemia: __Easy bruising/ bleeding: Tongue:
__History of STD & treatments: __Past transfusions & rxns: __Pica: Tonsils/pharynx:
__Sexual Preference, Interest, Function & Satisfaction: Parotid enlargement:
Endocrine: Other:
__Birth Control Methods, Condom Use & Problems: __Thyroid trouble: __Heat or cold intolerance:

2
Neck: Rubs: 5. calculation
Inspection Pulsus alterans: 6. fund of information
Carotid bruit: (R)___________; (L)__________ Peripheral pulses/bruits: 7. insight, judgment and planning
Venous hum: (scale pulses 0-4; normal – 3)
Thyroid: Edema: Speech:
Other: Right leg 1 2 3 4 A. Dysphonia:
Left leg 1 2 3 B. Dysarthria: (phonemes, vowels, consonants & labials –
Nodes: 4 CN VII; gutturals – CN X; linguals – CN XII)
Lymph nodes: Abdomen: C. Dysprosody:
Inspection: D. Dysphaia:
Chest: Auscultation:
Inspection: Bowel Sounds: Head and Face:
Chest structure: Bruits/ Rubs: A. Inspection:
Chest motion: Palpation: pain/ tenderness: 1. impression, gestalt, motility & expression
Retractions: Ascites: 2. shape & symmetry
Palpation: Liver: Auscultation: 3. hair of scalp, eyebrows, & beard
Tracheal position: Liver: shape/ size: 4. ptosis, palpebral fissures, relation of iris to lids,
Vocal fremitus: Spleen: papillary size, interorbital distance
Tactile fremitus: Inguinal canal: 5. contours & proportions of nose, mouth, chin &
Percussion: Other: ears
Resonant: B. Palpate
Hyperresonant: Male Genitalia: Lumps:
Dull: External male genitalia: Depressions or tenderness:
Flat: Temporal arteries:
Auscultation: Female Genitalia: Infants:
Crackles: Pelvic exam: (indicate sites of abnormality) fontanelles & sutures:
Rhonci: a. external genitalia occipitofrontal circumference:
Wheezes: b. vagina C. Percuss:
Stridor: c. cervix Sinuses & mastoid processes
d. uterus D. Auscultate: (bruits)
Breast: e. adnexa Neck vessels:
Mass: f. pap test: done: _____ not done:_____ Eyes:
Nipple/Areola: Other: Temples:
Mastoid processes:
Cardiovascular System: Rectal Examination: E. Transilluminate:
Jugular venous pressure: Rectal: Inspection/tone/hemorrhoids/masses: Sinuses:
Jugular venous pulsations: Prostate: Infants:
Clinical CVP: Other:
Apex beat location: Cranial Nerves:
PMI location: NEUROLOGIC EXAMINATION A. Optic Group: II, III, IV & VI
Carotid pulse: Mental Status Examination: 1. Inspect:
Heaves: A. General behavior and appearance: a. width of palpebral fissures
Thrills: B. Stream of talk: b. relation of limbus to lid margins
Lifts: C. Mood & affective responses: c. interorbital distance
Pulmonary artery pulsation: D. Content of thought: d. en- or exophthalmos
First heart sound: E. Intellectual Capacity: 2. Visual functions:
Second heart sound: F. Sensorium a. acuity (central fields): newsprint or Snellen
Third heart sound: 1. consciousness chart
Fourth heart sound: 2. attention span b. peripheral fields:
Click: 3. orientation to time, place and person - confrontation
Murmur: 4. memory, recent & remote 3. Pupillary Light Reflexes:

3
 Size of Pupils:
4. Ophthalmoscopy (findings):
5. Ocular motility:
a. fields of gaze
b. miosis during convergence
c. cover-uncover test
d. nystagmus
d. other eye movements:
B. Branchiomotor group and tongue: V, VII, IX,
X, XI and XII
1. V: masseter & temporalis bulk
2. VII:
a. forehead wrinkiling, eyelid closure, mouth
retraction, whistling or puffing out cheeks,
wrinkling of skin over nck
b. labial articulations
c. Chvostek’s sign:
3. IX & X:
a. phonation & articulation (labial, lingual, &
palatal):
b. swallowing, gag reflex & palatal elevation:
4. XII:
a. lingual articulations:
b. midline & lateral tongue protrusion:
c. tongue atrophy & fasciculations:
5. XI:
a. sternocleidomastoid & trapezius contours:
b. head movement & shoulder shrug:
6. 100 repetitive movements if with history of
pathologic fatigability:
7. assess rate, regularity & depth of breathing:
C. Special Sensory Group
1. Olfaction (I):
2. Taste (VII): salt or sugar
3. Hearing (VIII)
a. otoscopy
b. threshold & acuity: (conversational speech,
tuning fork, ticking watch or finger rustling)
c. air-bone conduction test of Rhine & vertex
lateralizing test of Weber
d. bilateral stimuli using finger rustling (if w/
history of cerebral lesion)
e. audiopalpebral reflex: (infants &
uncooperative patients)
D. Somatic Sensation of the Face:
1. corneal reflex (V-VII arc):
2. light touch over trigeminal area:
3. temperature discrimination over trigeminal area:
4. pain perception over trigeminal area:
5. buccal mucosal sensation (in selected patients):
Somatic Motor Systems:
A. Inspection:
1. gait testing: (free walking, toe & heel walking,
tandem walking, deep knee bend; child: hope &
run)
2. posture, general activity level, tremors & other
involuntary movement:
3. assess somatotype or body gesalt
4. observe size & contour of muscles: (atrophy or
hypertrophy, body asymmetry, joint
malalignments, fasciculations, tremors &
involuntary movement)
5. lesions: (neurocutaneous stigmate)
B. Palpation: (atrophic, hypertrophic, tender or spastic)
C. Strength testing:
1. shoulder girdle:
2. upper extremities: (biceps, triceps, wrist
dorsiflexors, grip; strength of finger abduction &
extension)
3. abdominal muscles: (sit-up)
4. lower extremities: (hip flexors, abductors &
adductors; knee flexors, foot dorsiflexors,
invertors & evertors)
* grading scale: 0 – paralyzed
1 – severe weakness
2 – moderate weakness
3 – minimal weakness
4 – normal
D. Muscle tone: (passive movements of joints to test for
spasticity, clonus, rigidity or hypotonus)
E. Muscle stretch (deep) reflexes)
1. jaw jerk (V afferent & efferent)
2. biceps reflex (C5-C6)
3. triceps reflex (C7-C8)
4. finger flexion reflex (C7-T1)
5. quadriceps reflex or knee jerk (L2-L4)
6. hamstring reflex (L5-S1)
7. triceps surae reflex or ankle jerk (L5, S1-S3)
8. toe flexion reflex (S1-S2)
F. Percussion: (thenar eminence for percussion myotonia;
myotonic grip)
G. Skin-muscle (superficial reflexes)
1. abdominal skin-muscle reflexes:
a. T8-T9 – upper quadrants
b. T11-T12 – lower quadrants
c. Beevor’s sign (umbilical migration)
2. cremasteric reflex (L1-afferent; L2-efferent)
3. anal pucker (S4-S5); bulbocavernosus reflex
4. extensor toe sign or Babinski sign (S1-afferent,
L5, S1-S2-efferent)
H. Cerebellar system:
1. finger-to-nose; rebound & rapid alternating hand
movements:
2. heel-to-knee:
I. Nerve root stretching tests:
1. leg raising tests (disc or low-back disease is
suspected):
a. straight-knee leg raising test (Laseague’s
sign):
b. bent-knee leg raising test (Kernig’s sign);
2. suspected meningeal irritation:
a. nuchal rigidity & concomitant leg flexion
(Brudzinski’s sign):
b. leg raising tests:
Somatic sensory system:
A. Superficial sensory modalities:
1. light touch over hands, trunk & feet
2. temperature discrimination over hands, trunk &
feet
3. pain perception over hands, trunk & feet
B. Deep sensory modalities:
1. vibration perception at knuckles, fingernails,
malleoli of ankles and toenails
2. position sense of fingers & toes (use 4th digits)
3. stereognosis
4. Romberg (swaying) test
5. directional scratch test
C. Determine distributional pattern of any sensory loss:
dermatomal, peripheral nerve(s), central pathway, or
nonorganic:
Cerebral Functions:
A. MSE
B. If MSE suggests cerebral lesion, test for:
a. agraphognosia
b. finger agnosia
c. poor 2-pt discrimination
d. right-left disorientation
e. atopognosia
f. tactile, auditory & visual inattention to bilateral
stimuli
g. tactile inattention to simultaneous ipsilateral
stimulation of face-hand & foot-hand
C. Halstead-Reitan cognitive, constructional &
performance tests for cerebral dysfunction
Case Summary or Clinical Impression:
______________________________________________
______________________________________________
______________________________________________
______________________________________________