REPUBLIC OF THE PHILIPPINES

Province of Dinagat
Municipality of Tubajon
Municipal Health Office

NAME: ______________________________________________ AGE:_____ DATE OF BIRTH:__________________ CIVIL STATUS:_______

(LAST NAME) (FIRST NAME) (MIDDLE NAME)
ADDRESS: _____________________________________________ CONTACT NO:______________ DATE & TIME:____________
(PUROK) (BARANGAY)
CHIEF COMPLAINT:____________________________________________________________________________
ONSET OF ILLNESS:___________ DURATION OF ILLNESS:__________
HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY

Previous Surgery:___________ Diabetes Mellitus:_________________
Hypertension:_____________ Cardiovascular Dse:________________
Lung Disease:______________ Kidney Disease:___________________
Cancer:___________________ Neurologic/Mental Condition:_______

SOCIAL HISTORY
Occupation:____________________ Allergies:___________________
Smoking:______________________ Alcohol:____________________

FAMILY HISTORY
Diabetes Mellitus:_________________ Hypertension:_____________
Cardiovascular Dse:________________ Lung Disease:______________
Kidney Disease:___________________ Cancer:___________________
Neurologic/Mental Condition:_______

REVIEW OF SYSTEM
ALTERED MENTAL SENSORIUM DIARRHEA HEMATEMESIS PALPITATIONS
ABDOMINAL PAIN DIZZINESS HEMATURIA SEIZURES
ANOREXIA DYSPHAGIA HEMOPTYSIS SKIN RASHES
BLEEDING GUMS DYSPNEA IRRITABILITY BLOODY STOOL
BODY WEAKNESS DYSURIA JAUNDICE SWEATING
BLURRING OF VISION EPISTAXIS LOWER EXTREMITIES EDEMA URGENCY
CHEST PAIN/DISCOMFORT FEVER MYALGIA VOMITING
CONSTIPATION FREQUENCY OF URINATION ORTHOPNEA WEIGHT LOSS
COUGH HEADACHE PAIN OTHERS:

PHYSICAL EXAMINATION
GENERAL SURVEY: AWAKE AND ALERT ALTERED SENSORIUM
VITAL SIGN: BP:_______ HR:______ RR:_______ TEMP:________
WT:________ HT:______ BMI:______ O2 SAT:_______

HEENT: Essentially Normal Abnormal Papillary Cervical Dry mucous

Icteric Sclerae Reaction lymphadenopath membrane
Pale conjunctivae y Sunken fontanelle
Sunken eyeballs
CHEST AND LUNGS Essentially Normal Asymmetrical Chest Decrease breath Wheezes
Lumps over breast Expansion sounds
Rales/crackles/ Intercostal rib
rhonci retr
CARDIOVASCULAR Essentially Normal Displaced Apex beat Heaves/thrills Hyperactive
SYSTEM Irregular rhythm Muffled heart sound Murmurs sounds
ABDOMEN Essentially Normal Abdominal rigidity Abdominl Hyperactive bowl
tenderness sounds
Palpable Mass Tympanitic/dull abd Uterine
contraction
GENITO-URINARY Essentially Normal BS in exam finger Cervical dilation Presence of
Mass abnormal
Others discharge

SKIN/EXTREMITY Essentially Normal Clubbing Cold Clammy skin Cyanosis/mottled

Edema/Swelling Decreased Mobility Pale Nailbeds skin
Poor skin turgor
Rashes/Petechiae Weak pulses
NEUROLOGICAL EXAM Essentially Normal Abnormal gait Abnormal Abnormal
Poor/altered position sensation
sense
Abnormal Reflexes memory Poor muscle tone Poor coordination
CLINICAL IMPRESSION:
REPUBLIC OF THE PHILIPPINES
Province of Dinagat
Municipality of Tubajon
Municipal Health Office
 REPUBLIC OF THE PHILIPPINES
Province of Dinagat
Municipality of Tubajon
Municipal Health Office

DIAGNOSTICS:

THERAPEUTICS:

FOLLOW-UP:

_______________________
MA. ISABEL A. JAMITO, MD
MHO/DTTB
License No. 164786