STUDENT NAME:

IDENTIFYING DATA
Name: Age: Sex: Status: Religion: ___________
Address: Date and Time of Admission:___________________________________

INFORMANT & RELIABILITY:

CHIEF COMPLAINT/S:

HISTORY OF PRESENT ILLNESS:

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PAST MEDICAL HISTORY:
Medical problems/ Previous Hospitalizations:
Illness and Medications taken:
Previous Surgery/Accident: ( ) Dengue Fever ( ) Typhoid Fever ( ) Asthma ( ) Pneumonia
Infectious and Medications Taken: ( ) Chicken pox ( ) Measles ( ) Mumps
Allergies: ( ) food:
( ) drugs:
FAMILY HISTORY: ( ) Hypertension ( ) DM ( ) Asthma ( ) PTB ( ) Epilepsy ( ) Malignancies ( ) Thyroid disease
( ) Hx of Convulsions ( ) Others:____________
PERSONAL-SOCIAL HISTORY:
Typical: _____________________________________________________________________________________
Lifestyle:____________________________________________________________________________________
Schooling: ___________________________________________________________________________________
Job History: _________________________________________________________________________________
Financial Situation: ____________________________________________________________________________
Marriage and Children: ________________________________________________________________________
Home Stituation: _____________________________________________________________________________
Diet: _______________________________________________________________________________________
Religious Beliefs: _____________________________________________________________________________
Vices:
Smoking: sticks per day____, started at age_____, Pack years_____
Alcoholic Beverages: drinks_________, consuming________ glasses/session, started at age______
Others:____________________________________________________________________________
OB HISTORY:
TT doses:
Menstrual History
Menarche:___Menstruation: reg/irreg, ____days, duration______heavy on the____day, consumes____
pads/da, Dysmenorrhea ( )
Contraceptive method used:
Prenatal Checkups:
Medications during pregnancy:
Previous Pregnancies:
RANK DATE SEX BIRTH WT PLACE DELIVERY TYPE AOG COMPLICATIONS
REVIEW OF SYSTEMS: Heart:
Inspection- PMI
General: ( ) weakness, ( ) recent wt. loss. Palpation- ( ) heaves, ( ) thrills
Skin: ( ) rashes, ( ) itching, ( ) scars Percussion- ( ) CAD
HEENT: Auscultation- ( ) regular rate and rhythm, ( )
 Head- ( ) headaches, ( ) dizziness, ( ) Trauma murmurs
 Eyes – ( ) excessive tearing, ( ) sore eyes,
( ) double vision Abdomen:
 Ears – ( ) tinnitus, ( ) vertigo Inspection-
 Nose & Sinuses – ( ) stuffy nose, ( ) rhinorrhea Auscultation- ( ) NABS
 Mouth & Throat – ( ) mouth sores, ( ) Percussion-
hoarseness, ( ) sore throat, ( ) dryness Palpation- ( ) organomegaly, ( ) tenderness,
Neck: ( ) stiffness, ( ) lumps ( ) vein engorgement location _______
Respiratory ( ) cough ( ) tachypnea ( ) dyspnea
Cardiovascular: ( ) palpitations ( ) chest pain ( ) elevated Back: ( ) CVA Tenderness
BP
Gastrointestinal: ( ) abdominal pain, ( ) vomiting ( ) LBM Genitalia:
( ) melena
Genito-urinary: ( ) dysuria ( ) anuria ( ) hematuria Anus:
Musculoskeletal: ( ) muscle pain, ( ) joint pain
Neurologic ( ) fainting spells, ( ) loss of sensation Extremities:
Hematologic: ( ) easy bruising Pulses- ( ) equal ( ) unequal, ( ) palpable, ( )
Psychiatric: ( ) nervousness ( ) depression ( ) anxiety non-palpable, ( ) weak ( ) strong, Capillary refill__ sec,
Endocrine: ( ) sweating ( ) heat tolerance ( ) polydipsia Edema, ( ) clubbing

PHYSICAL EXAMINATION: IMPRESSION:

General appearance:

VS:
BP Ht
PR Wt
RR Temp
O2 sat Hgb
Skin:

HEENT:
Head- ( ) Normocephalic, ( ) Symmetrical,
lumps, lesions
Eyes – ( ) sunken, ( ) icteric, ( ) anicteric sclera,
( ) pinkish palpebral conjunctiva, ( ) PERLA
Ears- ( ) well-developed pinnae, ( ) discharges,
( ) intact tympanic membrane
Nose & Sinuses- ( ) flaring of alae nasae,
( ) septum midline
Mouth & throat- lips ( ) dry ( ) moist, ( ) moist
buccal mucosa, ( ) tonsillar congestion

Neck: ( ) prominent neck cartilage, ( ) JV engorgement,

( ) trachea at midline

Chest & Lungs:

Inspection- ( ) equal chest expansion, ( )
intercostal & subcostal retractions
Palpation- ( ) tactile fremitus
Percussion- ( ) resonant over both lung fields
Auscultation- ( ) Broncho-vesicular breath
sounds