A.

GENERAL DATA

DATE THE HISTORY WAS TAKEN HISTORY TAKEN BY

INFORMANT 1/ RELATIONSHIP/ RELIABILITY

INFORMANT 2/ RELATIONSHIP/ RELIABILITY

SOURCE OF REFERRAL

B.IDENTIFYING DATA

FULL NAME

AGE/GENDER DATE OF BIRTH

BIRTHPLACE RELIGION

CIVIL STATUS NATIONALITY

OCCUPATION (PAST & PRESENT)

PRESENT ADDRESS

C.ADMISSIONS AT PRESENT HOSPITAL

NUMBER OF TIMES ADMITTED

INCLUSIVE DATES OF HOSPITALIZATION AND

REASONS (OPTIONAL)

CHIEF COMPLAINT

D.HISTORY OF PRESENT ILLNESS

E. MENTION OF PAIN (OPTIONAL)

ONSET LOCATION

DURATION CHARACTER

AGGRAVATING FACTORS ALLEVIATING FACTORS

RADIATION TIMING

F.PREVIOUS MEDICATIONS (IF APPLICABLE)

Drug allergies: ⏹ No ⏹Yes To what?______________________________

NAME OF MEDICINE/ VITAMIN/ MINERAL/ HERBAL SUPPLEMENT (NOTE IF SYMPTOMS DOSE FREQUENCY /# Pills How long have you been taking this
ARE ALLEVIATED)
 G. PAST MEDICAL HISTORY

Do you now or have you ever had:

Immunizations: Other medical Conditions/Notes

Diabetes Heart murmur Crohn’s disease Measles/tigdas
DPT
Hypertension Pneumonia Colitis Chickenpox/Bulutong
OPV
High cholesterol Pulmonary embolism Anemia Mumps/beke
IPV
Hypothyroidism Asthma Jaundice Pertussis
HEPA B
Goiter Emphysema Hepatitis Rheumatic fever
BCG
Cancer (type) Stroke Stomach or peptic ulcer Rubella
JAP. ENCEPHALITIS
______________
Epilepsy (seizures) Rheumatic fever
Leukemia ROTAVIRUS
Cataracts Tuberculosis
Psoriasis PNEUMOCOCCAL
Kidney disease HIV/AIDS
Angina FLU
Kidney stones Risks for STDs
Heart problems PENTA HiB
Blood Transfusions
Allergies RABIES
Hospitalizations/ Surgeries:
TETANUS TOXOID
__________________________
__________________________
COVID; BOOSTERS
__________________________
Mental illness

H. FAMILY HISTORY

IF LIVING IF DECEASED

MEMBER AGE HEALTH AND PSYCHIATRIC AGE(S) AT DEATH CAUSES

GRANDFATHER

FATHER

MOTHER

CHILDREN

SIBLINGS

HETERO FAMILIAL DISEASES

HETERO FAMILAIR DISEASES COMMUNICABLE DISEASES

DM TUBERCULOSIS

HYPERTENSION COVID

THYROID STDS

RENAL DISEASE OTHERS:______________

ALLERGIES

STROKE

HEART DS

ASTHMA/LUNG DS

SEIZURE

CANCER

I. PERSONAL AND SOCIAL HISTORY

Were there problems with your birth? (specify)___________________________________

⏹⏹ ⏹ ⏹ ⏹ ⏹⏹ ⏹ ⏹
Where were you born & raised?_________________________________________________

Marital status: ⏹
What is your highest education?
Never married
High school
Married Divorced
Some college
Separated
College graduate
Widowed
Advanced degree
Partnered/significant other

⏹⏹ ⏹ ⏹ ⏹⏹ ⏹ ⏹
What is your current or past occupation?________________________________________________
Are you currently working? :
Do you have a disability? Yes
Yes
No
No

Religion:____________________________________
Hours/week ______ If not, are you retired disabled
Have you ever had legal problems? (specify) Yes;__________________ ⏹
sick leave?
No
 LIVING CONDITIONS

SOURCE OF WATER WASTE DISPOSAL

RELEVANT TRAVEL
HISTORY

LIFESTYLE HABITS

SLEEP EXERCISE

DIET SEXUAL ORIENTATION AND

PRACTICES

ILLICIT DRUG USE ALTERNATIVE HEALTH CARE

PRACTICES

SMOKING HISTORY

STICKS PER DAY AGE STARTED AND AGE PACK YEARS

STOPPED

TOTAL YEARS
SMOKING

ALCOHOL INTAKE HISTORY

TYPES OF ALCOHOL AGE STARTED & STOPPED

FREQUENCY QUANTITY

J. MENSTRUAL HISTORY (IF APPLICABLE)

AGE OF MENARCHE

SUBSEQUENT MENSES

REGULARITY FREQUENCY

DURATION AMOUNT OF BLEEDING

PREMENSTRUAL DYSMENORRHEA
TENSION

LAST MENSTRUAL PREVIOUS MENSTRUAL

PERIOD (LMP) PERIOD (PMP)

MENOPAUSE (IF APPLICABLE)

AGE SYMPTOMS

USE OF HORMONAL POST MENOPAUSAL

REPLACEMENT BLEEDING

DIFFICULT/ PAINFUL
SEXUAL CONCERNS ABOUT HIV
INTERRCOURSE

K. OBGYN HISTORY (IF APPLICABLE)

# PREGNANCIES # OF DELIVERED LIVE BABIES

(GRAVITY) (PARITY)

WERE THE
CHILDREN FULL/
PREMATURE?

MANNER OF PLACE OF DELIVERY

DELIVERY

ABORTIONS (SPONTANEOUS &

COMPLICATIONS INDUCED)

BIRTH CONTROL BLEEDING BETWEEN

METHODS PERIODS/ AFTER
INTERRCOURSE
 A. REVIEW OF SYSTEMS

GENERAL SKIN EYES EARS NOSE/SINUSES

Recent weight gain; how Redness Pain Ringing in ears Change in smell
much____
Rash Redness Earache Pain around paranasal sinuses
Recent weight loss: how
Nodules/bumps Loss of vision Tinnitus Nose bleeding
much____
Fatigue Hair loss Double vision Ear discharge;quality:_______________ Nasal obstruction

Weakness Itchiness Blurred vision Loss of hearing Nasal discharge

Fever Dryness/Sweating Dryness

Chills Color changes of hands or Lacrimation

feet;cyanosis, erythema, jaundice,
Loss of appetite Use of glasses
pallor
Night sweats Heat/cold intolerance

MOUTH & THROAT NECK BREAST HEART & LUNGS NERVOUS SYSTEM

Sore throats Pain Pain Chest pain Headaches

Hoarseness Limitation of movements Lumps Palpitations Weakness

Difficulty in swallowing Mass Nipple discharge; quality:___________ Easy fatigability Speech disorder

Pain in jaw Paroxysmal nocturnal dyspnea Vertigo

Polydipsia Shortness of breath Paralysis

Toothache Fainting Dizziness

Gum bleeding Swollen legs or feet Fainting

Disturbance in taste Cough Numbness or tingling

Hx asthma Memory loss

Sputum: ___________ Confusion

Wheezing

Orthopnea (#pillows:_____)

GASTROINTESTINAL GUT BLOOD MUSCLE/JOINTS/BONES/EXTREMITIES PSYCHIATRIC

Nausea Frequent urination Anemia Numbness Depression

Heartburn Dysuria Clots Joint pain Excessive worries

Stomach pain Painful urination Easy bruising Joint swelling Difficulty falling asleep

Vomiting/regurgitation Urethral discharge Bleeding tendencies Muscle weakness Difficulty staying asleep

Hematemesis Blood in urine Hx of transfusion Edema ; Where?____________ Difficulties with sexual

arousal
Dysphagia Urgency Intermittent claudication
Poor appetite
Yellow jaundice Incontinence Limitation of movement
Food cravings
Increasing constipation Genital pruritus Stiffness
Frequent crying
Persistent diarrhea Lumps
Sensitivity
Blood in stools Sores
Thoughts of suicide /
Black stools Itching
attempts
Diarrhea Stress

Constipation Irritability

Poor concentration

Racing thoughts

Hallucinations

Rapid speech

Guilty thoughts

Paranoia

Mood swings

Anxiety

Risky behavior
OTHER PROBLEMS/NOTES:

B. VITAL STATISTICS

BLOOD PRESSURE RESPIRATORY RATE

HEART RATE/PULSE TEMPERATURE

RATE

HEIGHT WEIGHT

BMI WAIST CIRCUMFERENCE

C. PHYSICAL EXAMINATION

(1)GENERAL SURVEY (3)NECK, CHEST AND NECK

APPEARANCE/FACIAL EXPRESSION:___________
ABDOMEN
JVP
SIGNS OF DISTRESS:_____________
MASS
HYGIENE/ODOR:____________
CHEST & ABDOMEN
SCARS INSPECTION

LEVEL OF CONSCIOUSNESS: ________ SKIN LESIONS

POSTURE BRUISING

GAIT SCARS

PERCUSSION

LUNG APICES

ABDOMINAL ORGANS

SHIFTING DULLNESS

PALPATION

APEX BEAT

ABDOMINAL ORGANS

AUSCULTATION

LUNG BASES

RENAL BRUIT

(2)HEAD AND FACE (4)EXTREMITIES

HAIR EDEMA

SKIN COLOR MUSCULATURE (ATROPHY?)

CONJUNCTIVAL PALLOR TURGOR

LESIONS TREMOR

HEMORRHAGES

KOILONYCHIA

BRUISING

TOPHI

SKIN LESIONS

CRANIAL NERVE EXAMINATION

CN I (Olfactory Nerve) CN VIII (Vestibulocochlear

Coffee, Oil of lemon, Vanilla Weber’s Test
Nerve)
Rinne’s Test

CN II (Optic Nerve) CN IX (Glossopharyngeal

Pupillary Reflex Posterior ⅓ of the tongue
Nerve)
Visual Acuity

Color Vision Testing

Visual Field Testing

Optic Nerve Evaluation (Ophthalmoscopy)

 CN III (Oculomotor CN IX (Glossopharyngeal
Left/Right Superior Rectus Gag Reflex
Nerve), IV (Trochlear Nerve) and X (Vagus Nerve)
Nerve) and VI Left/Right Inferior Rectus Phonation
(Abducens Nerve)
Left/Right Medial Rectus Pharyngeal and Laryngeal Movements

Left/Right Lateral Rectus Deviation of the uvula

Left/Right Superior Oblique

Left/Right Inferior Oblique

CN V (Trigeminal CN XI (Accessory Nerve)

Sensory Motor
Nerve)
Sharp/Dull Sensation Sternocleidomastoid Muscle

V1 (Ophthalmic) Trapezii

V2 (Maxillary)

V3 (Mandibular)

Motor

Palpate the masseter muscles

Muscle strength of the lateral pterygoids

CN VII (Facial Nerve) CN XII (Hypoglossal Nerve)

Inspection: Tongue atrophy

Facial Symmetry Fasciculations

Sensory: Anterior ⅔ of the tongue Tongue Deviation

Motor

Frontal muscles

Orbicularis oculi

Platysma muscles

REFLEXES OTHER NOTES

BICEPS REFLEX

TRICEPS REFLEX

KNEE JERK REFLEX

ANKLE REFLEX

BABINSKI REFLEX