HI

STORYANDPHYSI
CALEXAMI
NATI
ON CurrentMedi
cati
ons:
Generic Brand Dosage Fr
equency Pur
pose
DateofInt
ervi
ew: KremilS PRN
Ti
meofHi story: Ranit
idi
ne 150mg? PRN
I
nformant:pati
ent
Rel
ati
onshiptothePat
ient
:__
___
___
___
___
___
___
__
%Reliabi
li
ty: Immuni zat i
ons:
 BCG  DPT  Pol io  HepaBok
Gener alData: Others: Measles
Pati
ent ’
sName: Allergi
es:
Age: __Sex: _
_Mar it
alStat
us:__ Food: none
Addr ess: Medicat i
ons:none
Bi
rthday :_
__ _
______Bir
thpl
ace:__
_____
____ Poll
en/ Animals/
Other
s:none
Nationali
ty:_____
_Religi
on:___
_____
____​ Chi l
dhoodI ll
ness:
Occupat i
on: __
_______
_ r heumat icfev
er  pol
io
 chickenpox  measles
Dat
eofAdmission:  mumps
Ti
meofAdmi ssi
on: others:______
_____
___
____
___
___
____
__
No.oft
imesadmitt
edatCVMC: Adul tI
ll
ness:
Il
l
ness Age Dat
eofDi
agnosi
s
Chi
efCompl
aint
: Hyper t
ension
Str
oke
HistoryofPr esentI ll
ness: Renal
Onset :____________________
_ ____
_ _
____ Asthma
Durat i
on: ____
__ _
_ ______
_______________ TB
Frequency :_
_____ ____
_____________ DM
Setti
ngatwhi cht heSy mpt om Occur red:_____
_________
_______
__ Cardiac
__________________ _
_____________
_ _
__________
_________
__ GI
Mani festati
ons: ___________
_ ____
_ _
_________
_________
_______ STD
Location: ____
________________
_________
_________
__ Others
Precipitati
ngFact ors:_______
_________
_________
______
Quality:________
________________
_________
________ Surgi
calProcedures:
Radiation: _
_______________
__________
_________
____ Date:_______
_____
_____
_____
_____
____
Severity:_______
________________
_________
________ TypeofOper ati
on:____
_____
_____
_____
__
Aggr avatingFact ors:househol dchores Purpose: _
_____
_____
_____
_____
_____
___
All
ev i
atingFact ors: ___
________________
_________
_________
___ Previ
ousHospi t
ali
zati
ons:
PreviousTr eatmentf orthePr oblem: __
_________
_________
______ Date Cause Hospi
tal Tr
eat
ment
Associ atedSignsandSy mpt oms: _______
_________
_________
____
__________________ _
_____________
_ _
__________
_________
___
Perti
nentPosi t
ivesandNegat iv
es: __
__________
_________
______
_
__________________ _
_____________
_ _
__________
_________
___
Additional Notes: ______
________________
_________
_________
__ ScreeningTest s:
__________________ _
_____________
_ _
__________
_________
___ Test Dat
e Resul
t
__________________ _
_____________
_ _
__________
_________
___ Tuberculintest
PapSmear
Mammogr am
Occultbloodi nstool
Cholesteroltest
Uri
nalysis
Xray/CTScan/ MRI
Others

Menstrual andObst etri

cHi story:
LMP: ________
_ ___ PMP: ______
_________
Ageofmenar che: _________
_ __Peri
od: r
egular/ir
regular
Characterofflow: ____________
Durati
onofper iod(range):________
____
No.ofpadsusedperday :__________
__
PMS: ___________________
____________
__________________
__
AgeofMenopause: ___
_ _
__
Ageof1stcoi tus: _
_______ No.ofsexual part
ner s:_____
___
__
Hist
oryofpost -coi
talbleeding,pelvi
cinfecti
on, dyspareuni
a?
Bi
rthcont r
ol met hodsused:
Arti
ficial Natural
 condom r hythm met hod
 pills  withdrawal
 sper micidal  abstinence
Other s:____
_____________
__________
_ ______
__
Lengt hoft i
meused: _____
____
Compl i
cati
ons: ______
___________
_____ __
______

Gr
avidi
ty:
_____
_ Par i
ty:____
___
OBIndex:__
____
__Term
_
_____
__Preterm
PastMedi
cal
Hist
ory
: _
_____
__Abor t
ions/Mi
scar
ri
ages
 ____
____Liv
ingChi
l
dren Rel
at i
onshiptooccupants:______
________
________
____
DateofBi
rt
h Sex MannerofDel
iver
y ___
__ _
________
______
_______
_ _
______
________
_____
__
_____
___
_____
_____
__ ____
_____
___
___
___
__ SourceofDr i
nkingWater:deepwel l
__
_____
___
_____
_____
__ ____
_____
___
___
___
__ GarbageDi sposal
:_____
________
________
________
____
__
_____
___
_____
_____
__ ____
_____
___
___
___
__ FecalDisposal:__
______
________
________
________
___
Pet/s:___
________
_____
_________
________
________
_
OBHx:G_P_( T-
P-A-L) Personall
ygivesbathtopet s?Y/N
G1:When_ _
______
_,NSDorCSd/ t_
_____
___,
del
iver
edby_
_ _
___
___
, GeneralStateofneighborhood:______
________
______
_
wher
e____
_____,M/F,weight___
_ _
___
_,f
etomater
nal
compli
cat
ions
__
___
___
_____
______
__,presentstat
us___
_____
__. Rev i
ewofSy stems:
Const it
ut i
onal:
 Fev er  Wei ghtgain/l
oss
Fami l
yHist
ory
:  Chi ll
s  Fat i
gue
Fami l
y Age Healt
h/ Age&Date Causeof Skin:
Member Diseases ofDx death  Rashes I tching
Father  Lumps  Dr yness
Mot her  Col orChange  Changesi nNai l
s
Others Hair:
 Bal dness  ExcessHai r
Head:
 Headache  Dizzi
ness
¬¬ Li ghtheadedness  Trauma
Medi cal Problemsf
oranyblood-rel
ati
ve  Sy ncope  Tenderness
Rel
ationshiptoPx Age&Dat
eofDx Eyes:
Cancer  Pai n  Redness
Hy pertensi on  Doubl eVision  Blurr
edVi sion
Diabet es  UseofGl ass/Lenses  Photalgia
Tuber culosi s  Lacr imat i
on
Hear tDisease Ears:
Stoke  Hear ingPr oblem  Earache
KidneyDi sease  Di scharge( color/
consistency)____
____ _
_ _
_
Arthrit
is  Tinni tus  Verti
go
BloodDi sor der NoseandSi nuses:
Ast hma Mother  Epi staxis  Nasal stuffi
ness
Epilepsy  Di scharge( color/
consistency):_
___________
Ment al Disor der I tching
Mout handThr oat:
 Useofdent ures  Mout hsor es
Personal andSoci al History:  Bleedi ngGums  Toothache
No.ofy ear smar ried: 35_ _____  Sor et hroat  Hoarseness
HealthSt atusofSpouse: ______________  Dy sphagi a
No.ofChi l
dren: 10_ __ ____ Neck:
HealthSt atusofChi ldren: _______
_ __
_ _____
_________
_ _
________  Pai n  Stif
fness
HighestEducat ional Attainment :_______________
___________
____  Lump
Occupat ional Hist or y:___ ______
_ _
_ __
_ ____
__________
_ _
________ Breast :
________________ __ ___ _______________________
___________
________
___
___  Pai n  Discharge
________________ __ ___ ______________________  Lumps  Periodi
cExam
Occupat ional Hazar ds: ____________________
___________
______
Smoki ngHabi ts: Respi ratory:
 non- smoker  smoker ex-  Cough  Sputum (
color /quant it
y)_______
_
smoker  Hemopt ysis  Dysnea
No.ofst icks/ packsperday :_____
____  Wheezi ng
Yearst ar ted: ______Yearqui tted:______ Cardi ovascul ar:
Alcohol Consumpt ion  ChestPai n  Palpi t
at i
ons
 nev er  occasi onally  Or thopnea  Edema
 dai ly  weekl y  Cy anosi s  Par oxy smal Noct ur
nalDyspnea
Alcohol ty pe: ___________________  EasyFat igabilit
y
AmountConsumed: ______________ Gast rointest i
nal:
Nutri
tion:  Lossofappet it
e  Nausea
No.ofmeal sperday :________  Vomi ting  Hemat emesi s
Foodpr efer ences: __________________
_  Abdomi nal pai n  Diarrhea
Coffee/ tea/ sodai ntake: _________
______  Hemat ochezi a  Excessi vebelching/passi
ngofgas
Nut r
ientSuppl ement ::____________
____ Renal :
OTC: _______ _
_ ___ __ _______ __  Dy sur i
a  Poly uria
Prohibit
edDr ugs: __ ______ ____
_  Noct uria  GrossHemat uri
a
SubstanceAbuse: __ ______ _
____ I ncont inence  Urinar yRet enti
on
Exercise: _
__ _
_ __ ___ _______ __
________________  Ur inaryUr gency  Tea- Col oredUrine
RegularityofSl eep: 5hour s_________ _
___________
______ InMal es:
Habits/hobbi es: __ __ ______ _
___________________  Reducedcal i
berofforceofst r
eam
SourcesofSt ress: _ _______ ___
____ _
__ _
________  Hesi tancy
CopingSt r
ategi es: _ ______ _____
___ _
__ __
_ _
_____  Dr ibbling
Li
v i
ngCondi ti
ons: Genit ali
a:
No.ofy ear si ncur r
entr esidence:_35y ears_____
_  Pai n  Swelli
ng
Previouspl aceofr esidence: _______
_____  Di schar ge( char acteri
sti
cs):_
_____ ____ _
_ __
__
______ ___ ___ ____________________
___  Ul cers Itchi
ng
Typeofr esi dence: ________ _
__________ Peripher al vascul ar:
No.ofr ooms: ___________________
____  Legcr amps  Var i
cosev ei
ns
No.ofoccupant s:_______________
_____ Muskul oskel etal:
 Muscl eweakness  Sti
ff
ness
 Backache  Joi
ntswell
i
ng Ears:
 Muscl epai n  Joi
nPain Symmet ry:___
___________
_
Neurologic:  Swelli
ng:________
_ _
_ _
__ _
_________
______
 Paralysi s  Numbness  Redness: __
_______________
_________
____
 Tremor s  Sei
zur
es  Discharge:____
_______________
_________
__
 Memor yLoss  Tenderness:_______________
_________
_____
Hemat ologi c:  HearingImpairment s:_______
_________
_____
__
 Easybr uisi
ng  Bl
eedi
ng  PresenceofHear ingAi d:_____
_________
_____
__
 Pall
or WeberTest :____
_______________
_________
__
Endocrine RinneTest:(R)AC_ _________BC_ _______
___
 Polydy psia  Polyphagia (
L)AC_ _________BC_ _
_________
 Heat /coldintol
erance  Excessivesweat
ing
Psychiatric: Nose:
 Nervousness  Depression Symmet ry:____________
________
_______
 Anxiet y  Hall
ucinati
ons Frontal
,maxi l
larysinustenderness:_____
___
___
___
___
___
Obstructi
on: _
_ _
_ _
__________
________
___
PHYSI
CALEXAMI
NATI
ON Congestion:_____________
________
_____
Lesions:__________
_ _
________
________
_
Gener al Survey: Exudates:______________
________
______
Mood: _ __
________
_ __ I
nflammat ion:___________
_______
_______
Distress/Unusual Posit
ion:___
_____
____
_
Cooper ati
ve/Non- cooperati
ve Throat:
I
rrit
abl e/agit
ated/pleasant Li
ps: _
_ _
___________
_______
Coher ent :__
_______ Teeth/dentures:____
_______
________
____
Orientedt ot i
meandspace: _____
__ Gums: __________
_______
________
______
Personal Hygiene:______
______
___ Tongue: __
_ _
_ _
_______
_______
________
_
Lev elofConsci ousness: __
_____
_____
___ Pharynx:
Height :_________
___  Lesions:_____
________
_ Eryt
hema:____
_____
____
Wei ght: ___
_________  Exudates:_______
______Tonsi
l
larSi
ze:
_____
____
BMI :__ ____
________
Neck:
Vit
al Si
gns: Symmet r
y:________
________
_________
Temper ature:____
____  Oral Axi
ll
ary Rectal Li
mitationofROM: ________
__________
Respirat
ion: _
________  Normal Labored Tenderness: ___
_________
_________
_ __
_
Pulse:_________
____ Regul
ar R.I r
reg. I
rr
.ir
reg. JVD: _
__ _
___________
________
_______
Bl
oodPr essure:____
___  Lyi
ng Sitt
ing Standi
ng Lymphnodes: _______
________
_ _
_______
Size:____
________
_
Head: Mobi l
it
y:______
_____
Trauma: _
______
_______
__________
_______
_ Tenderness:__________
__ _
Si
z e:
________
______Shape:_______
______ Borders:_____
__________
_
Tenderness:___
_______
__________
_______
_____
__ Consistency:____
_________
Conditi
onofhairandscal p:___
_______
_____
_____
___
___
___
__ Thyroi
dcar til
age:_____
________Cricoidcar
ti
lage:
___
___
___
___
__
Symmet ry:_
______
_ _
_____
_ __
_______
___ Thyroi
dgl and:________
________
Masses: __
______
_______
__ _
_______
____
ChestandLungs
Eyes: I
nspect ion
Visualacuity: Comf ortandBr eathi
ngPat tern:____________
_ __
______
Far:( R)_ _
______( L)________ Shapeoft heChest :___________________
___________
Near :(R)________( L)_______
_ ChestMov ement : __
____________________
__________
VisualFiel
ds( Ht est):__
_ _
_________
______  UseofAccessor yMuscl esofBr eathi
ng: _____
________
_
Accommodat i
on: _____
__ _
________
_______  Defor mi tiesofAsy mmet r
y :_
____ _
_____________
______
Testofconf rontation:_______
_________
___  A/NRet racti
onofI nterspacesonI nspir
ation:______
_____
Conjunctiva: I mpai rmentofRespi r
atoryMov ement :________
________
Color: ____
___________
_________
____ ColorofPat i
ent(Lips&Nai lBed):______________
_____
Dischar ge:_______
_________
________ Palpation
Scler
ae:  TenderAr eas:_ _
____________________
____________
_
Color: ____
___________
_________
____ Respirator yExpansi on(10thrib):Symmet r
y Yes  No
Dischar ge:_______
_________
________ Tacti
leFr emi t
us: Symmet ry 
Cornea: Increased Decr easedAbsent
Clarit
y: ___
___________
_________
____ Percussi on: __________
____________________
__ _
___
Corneal Ar
cus: ___
________
_________
_ Auscultat ion
Li
ds: ___
_ _
_ _
__ _
_ ___ I r
is:_____
________
___ BreathSounds: _________
_ __
_ _
___________________
Positi
onofey esinor bi
ts:________
_________
_____
___
___
__  Bronchophony  Whi speredPet oril
oquy
Pupil
:  Egophony

Si
ze: (
R)_ _________( L)_______
_ _
__ Heart:
Shape: ____
__ __
__ _
_Sy mmet r
y:______
_____
___ I
nspect i
on
Accommodat i
on: ___
_________
___ Precordialbul
georheav e:_______
______
_____
Li
ghtref l
extest( PERLA) :
__________
_____
_ PMI :__
__ _
____
_ _
__ _
____________
EOM: ________________
________ Palpati
on
Vi
sual Fiel
d:_ __
__ _
_________
_________
____ PMI :__
__ _
____
_ _
__ _
____________
Dir
ectReaction:
_ ___
___ _
____Consensual Reacti
on:___
___
___
___ Thril
l
: _
__ _
_
Fundoscopi
c Locati
on: __
_ _
_ ___
________
_
Redor anger efl
ex: _
_________
____ TiminginCar diacCy cl
e(S/D):__
_____
___
___
_
Disc:_______
_ ___
_ __
_________
_ ModeofExt ension/Transmissi
on:___
___
___
___
Macula: ___
__ __
__ _
_________
__  Frict
ionRub: ______
_ _
_ ___
_______
Bloodv essels:________
_________ Percussion:CardiacBor ders
 Ri
ght(
cm) I
CS/MSL Lef
t(cm) Name:  Season Dat e Day Mont h Year
5th Name:  Hospi tal Fl oor Town St ate Count r
y
4th Levelofconsci ousness:
3rd B.Speech( Nor mal ,dysphasi a,dy sart
hria,dysphonia)
- 2nd C.Language
Auscult
ation Name:  Penci l Wat ch
S1(M-loud, T-spli
t)
:____
______
______
___ Repeat : “ Noi fs ands orbut s”
S2(A,P-l
oud, P-
spli
tI)
:_____
______
_____
___ D.Gener al Knowl edge
S3:______
_ ________
_____
_____ Knowl edgeofcur rentev ents, vocabulary
Murmur s/Accessor yHeartSounds: (Histor ical ev ent s,5l astpr esi dents,5largestcit
ies)
Locat i
on:___
______
______
___Timing:__
_____
_____
___ E. Memor y
Qual i
ty:_
______
______
______Pit
ch:____
_____
_____
__ Immedi at e,recent ,remot e
Intensi
ty:__
______
______
____Radiat
ion:__
_____
_____
_ F. Regi strat ion( Ret ent ionandr ecall
)
Ident i
fy : Obj ect1 Obj ect2 Obj ect3
Breast: Attent ionandCal culation
Symmet ry:_____________ (100- 7…) : 93  86  79  72  65
 Dimpling/SkinRet racti
on: __
_____________
______ Recal l
 Swelli
ng: _______________
_____ Recal l: Obj ect1  Obj ect2  Obj ect3
 Discolorati
on( Skinchanges) :_________
________ G.Reasoni ng
 OrangePeel Effect:_______
__________ Judgment ,
Insi ght ,abst raction( i
nterpretati
onofpr over
bs)
Posit
ionandChar acteri
sti
cofNi ppl
e: ______
________
___ H.Obj ectr ecogni ti
on
 Gynecomast i
a( Mal e):_
________
__ ___
___ Agnosi a( Visual ,tact i
le,audi tory,autotopagnosia,anosognosi
a)
 Mass: Praxis( Ideomot or ,Ideat i
onal )
Location: _____
________
____ _
________
___ Percept ion( Del usion, Hal lucinat i
on,il
lusion,ast
ereognosis,
Size:__ __
__ _
____ Consi stency:____
_______
_____
_ agraphest esia)
Tender ness: ___
________
__ _Mobi l
it
y:_____
_____
___ I
. Fol lowsCommand
Border s:________
________
_  Taket hispaper . Fol di tinhal f
. Pl aceitont het
able.
 Obeywr i
ttencommand.
Abdomen:  Wr iteasent ence.
Inspect ion  Copyadesi gn.
I rregul arCont our s:_________
___ Scar s Total:_
_ ___
 Di scol oration: ________________
 Bul ges: ________ _____
_ ___
____ Cranial Ner veExami nati
on
Shape: __ __
_ _______ ___
__ ___
_ CNI
 St ri
ae: _________ _____
_ ___
____ I dent ifyodor ant
Distanceofumbi l
icusf rom xiphoidprocess:__
_ __
_____ CNI I
Abdomi nal Gi rth:___ _
______________ Visual acui ty:________Vi sual fi
eld:_________
Auscul tat i
on Fundoscopy :______________ _____________
_________
____
___
_
Bowel Sounds: Frequency :__
_________Character:__
_____
___
__ CNI II
, IV, VI
 Br uit:_ __
_ _______ ___
__ ___ SizeandShapeofPupi l:___ ______________
_
 VenousHum: __ __________
__  LightReact i
on  Accommodat ion
 Fr i
ctionRub: _
__ __________
__ EOM:
Percussi on  Par esi s  Ny stagmus
LiverSpan: ____ _
__ _____
_ __Normal :6-
12cm in( R)MCL  Saccades  Ocul omot orAtaxia
SplenicDul lness: _ _____
_ ___
____  Dipl opi a  Ot her__________
___
OtherAr easofDul lness: ____
_________
__ CNV
Speci alTest s  Opht hal mic  Maxi ll
ary
 ReboundTender ness: Rovsing’s,
Blumberg  Mandi bular  Cor nealRef l
ex
 Cost ov ertebral Tender ness  JawCl ench
 Shi fti
ngDul l
ness CNVI I
 PsoasSi gn  Ey ebr owEl ev at
ion  For eheadWr inkl
ing
 Mur phy ’sSi gn  Ey eCl osur e  Smi li
ng
 CheekPuf f
ing
MaleGeni tali
a: CNVI II
 PenileLesions: _____
______
____  Hearf ingerr uborwhi sper edv oi
ce
 ScrotalSwel l
ing: _
______
______
__ __
___
___ Rinne: ___ _________Weber :_ ___________
Testi
cles CNI X, X
Size:__ _
_____ Tender ness:_
___
___
___
_ PalateandUv ula:_ ___
___ ______
 Masses: ____
______
___ _  GagRef l
ex
 Var icocoel
e:______
___ _
____
___ CNXI
 Hernia:_______ _
______
__  Shoul derShr ug( againstr esistance)
Transi
llumination: _
______
______
___  HeadRot ati
on( againstr esistance)
CNXI I(Tongue)
Ext
remi
ti
es:  At rophy  Fasci cul
ation
Amput at
ion Visi
blej
ointswel
l
ing Positionwi thprotrusion: _________
 Deformit
ies Li
mitati
onofROM Strengt h: ____
__ __
__
Tenderness Redness
War mth Edema MotorExami nat
ion
Inv oluntaryMovement
s
Capi
ll
aryrefi
ll
:__
_____
_____
__  Symmet ry
Peri
pheralpul
ses:_
_____
_____  Atrophy
 Gait
 Paresis
NEUROLOGI
CALEXAMI
NATI
ON  Paralysis
 Spast i
city
MentalSt
atusExami
nat
ion  Ri
gi dit
y
A.Awar eness  Fl
acci di
ty
Ori
entat
ion  Clonus
  Carpopedal
Spasm
 Ti
cs
 Tremor s
 Athetosi
s
 Others

Tone
Descri
pti
on:__
___
___
___
___
___
___
___
___
__
 Fl
accidi
ty
 Spasti
cit
y

Muscl
eSt
rengt
h

(
R) (
L)
ShoulderFl exion
Extensi on
Abduct i
on
Adduct i
on
IR/ER
Fl
exionatt heel bow
Extensionatt heelbow
Extensionatt hewr i
st
Squeeze2ofy ourfi
ngersashar
daspossi
ble
Fi
ngerabduct i
on
Opposi t
ionoft hethumb
Fl
exionatt hehi ps
Adduct i
onatt hehips
Abduct i
onatt hehips
Extensionatt hehips
I
R/ ER
Extensionatt heknee
Fl
exionatt heknee
Dorsifl
exionatt heankle
Plantarflexion

Coordinati
onandGai t
 RapidAl t
ernatingMov ements
 PointtoPoi ntMov ements
 Romber g
Gait
 Walkacr osst heroom, t
urnandcomeback
 Walkheel -t
o-toeinast r
aightli
ne
 Walkonheel sinastraightli
ne
 Walkont oesinast r
aightli
ne
 Hopi nplaceoneachf oot
 Shallowkneebend
 Risef r
om asi tt
ingpositi
on

Refl
exes
DeepTendon
 Biceps
 Triceps
 Brachi oradi
ali
s
 Knee
 Ankle
Superficial
 Abdomi nal
 Cremast eri
c
Refl
exesi nInf
ants
 Grasp
 Suck
 Mor o
 Root ing
 Tonicneck
 Babinski

Sensory
 Pinpri
ck
 Touch
Twopoi ntdiscri
minat
ion
 SenseofPosi t
ion
 Vibr
atorySense
 Superf
icial
sensati
on
 DeepSensat i
on