HSP-001A-MED-0

PIDDIG DISTRICT HOSPITAL

Piddig, Ilocos Norte

Name of Patient _____________________________ Age ______ Sex ___________

Room / Ward _______________________ Hospital No. ______________________

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:
HISTORY AND PRESENT ILLNESS:

PAST MEDICAL / SURGICAL HISTORY:

FAMILY HISTORY:

PERSONAL AND SOCIAL HISTORY:

Drug Therapy:
Tobacco / Alcohol intake:
Drug Allergies:
Other Allergies:

REVIEW OF SYSTEM
General:
Skin:
HEENT:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Reproductive:
Musculoskeletal:
Nervous:
 HSP-001B-MED-0

PIDDIG DISTRICT HOSPITAL

Piddig, Ilocos Norte

Name of Patient _____________________________ Age ______ Sex ___________

Room / Ward _______________________ Hospital No. ______________________

PHYSICAL EXAMINATION:

Vital Signs: BP HR RR T
Ht: Wt:

Skin:

HEENT:

Lungs:

Heart:

Breast:

Abdomen:

Genital:

Rectum:

Extemities:

Neurological:

ADMITTING DIAGNOSIS:

PLANS:

_______________________________
Attending Physician