HISTORY

General Data
Name (Guardian)
Age/ Sex
Handedness
Marital Status
Educational
Attainment
Occupation
Religion
Residence
Province
Chief Complaint/ History of Present Illness
Onset / Course
Provocation
Palliation
Quality
Region/ Radiation
Severity
Time
Associated
Symptoms

REVIEW OF SYSTEMS
System (+/-)
(-) change in appetite, (-) fever or chills, (-) fatigue, (-) weight gain, (-) weight loss, (-) muscle
Constitutional
ache , (-) change in sleeping pattern/time
Head (-) headache, (-) head injury, (-) dizziness
Ears (-) hearing loss, (-) tinnitus, (-) ear ache, (-) ear discharge
(-) use of glasses/contacts (OS: ; OD: ), (-) astigmatism, (-) vision loss or changes, (-) eye
Eyes
discharge, (-) eye pain, (-) eye redness, (-) blurry vision, (-) double vision, (-) flashing lights
Nose (-) nasal stuffiness, (-) nasal discharge, (-) nasal pruritus, (-) epistaxis, (-) sinus pain
(-) gum bleeding, (-) sore tongue, (-) sore mouth, (-) dry mouth, (-) sore throat, (-) hoarseness,
Throat (-) oral thrush, (-) dental caries, (-) lumps, (-) neck pain, (-) neck stiffness, (-) dysphagia, (-)
dysarthria
(-) cough, (-) colds, (-) sputum (-)​hemoptysis, (-) wheezing, (-) painful breathing, (-) shortness
Respiratory
of breath
(-) chest pain, (-) chest tightness, (-) palpitations, (-) orthopnea (-) Paroxysmal Nocturnal
Cardiovascular
Dyspnea
(-) abdominal pain, (-) nausea, (-) changes in bowel habits, (-) flatulence, (-) heartburn,
Gastrointestinal (-) constipation, (-) melena, (-) hematochezia, hematemesis, (-) difficulty swallowing, (-)
tenesmus
 (-) polyuria, (-) dysuria, (-) nocturia, (-) hematuria, (-) myoglobinuria, (-) incontinence, (-)
difficulty or pain in urinating, (-) change in urinary strength
Frequency of urination: frequent; 8x a day
Genitourinary
Urine Color: light yellow
(-) vaginal discharge, (-) foul odor, (-) menorrhagia, (-) dysmenorrhea, (-) amenorrhea, (-)
pruritus, (-) dyspareunia
Extremities (-) edema, (-) arthralgia, (-) stiffness, (-) back pain, (-) trauma, (-) pain

(-) jaundice, (-) pallor, (-) cyanosis, (-) petechiae, (-) ecchymoses, (-) rashes, (-) masses, (-)
Skin
pruritus, (-) dryness, (-) hair or nail changes

Neurologic (-) syncope, (-) seizures, (-) weakness (-) numbness, (-) paresthesias, (-) tremor
Endocrine (-) polydipsia, (-) polyphagia, (-) polyuria, (-) heat/cold intolerance, (-) hair loss
(-) nervousness, (-) stress, (-) depression, (-) memory loss, (-) hallucinations, (-) delusions, (-)
Psychiatric
illusions

OTHER HISTORY INFORMATION

Asthma Surgery
Allergies Polycystic Ovarian Syndrome
Allergic Rhinitis Thyroid enlargement
Atopic Dermatitis Liver Disease
Chickenpox Kidney Disease
Past Medical Mumps Heart Disease
History Measles Stroke
Mental Illness Polio
Pneumonia Hospitalization
Tuberculosis Injuries
Diabetes Trauma
Cancer Others:
Hypertension
Diabetes
Family Medical
Heart Disease
History
Autoimmune Disease
Others: ______________________
Dietary habits
●
Smoking history
●
Alcohol intake
Personal and ●
Social History Illicit drug use
●
Travel history
●
Sexual history
●
Obstetric and ● LMP
 Gynecologic ● PMP
● Menarche age
● Menstrual duration
● Light/ moderate/ heavy
● # of pads per day
Dysmenorrhea (relieved w/ _______________)
Sexually active
Contraceptive use: _______________
● Obstetric score

PHYSICAL EXAM
Systemic PE (sample)
● General Survey: awake, not in cardiorespiratory distress
● Vital Signs: BP: 120/70 HR: 84 (regular) RR: 20 Temperature: 36.7°C O2 sat:
● HEENT: Pink conjunctiva, anicteric sclerae, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion, (-)
neck vein engorgement, no carotid bruits, no anterior neck mass
● Chest/Lungs: (-) chest deformities, midline trachea, (-) palpable masses, symmetrical chest expansion (no chest
lag), clear breath sounds, (-) adventitious sounds, (-) retractions, (-) use of accessory respiratory muscles
● CVS: Adynamic precordium, distinct heart sounds, normal heart rate and rhythm, no murmurs, (-) heaves, thrills
● Abdomen: Soft abdomen (-) masses/tenderness on palpation, normoactive bowel sounds
● Skin / Extremities: good skin turgor, pink nailbeds, full and equal pulses, no cyanosis, no clubbing, no jaundice
● DRE: Good sphincter tone, empty rectal vault, no stool/blood per examining finger

Mental Status Assessment

Link to MMSE Questionnaire (Filipino) + Instructions to Administrators
Mental Status Assessment – Listed below are normal findings, change as needed
Normal: Awake, follows commands
Sensorium
Others: drowsy (can be aroused upon light tapping), stuporous (reacts with pain), comatose
Well groomed, dressed appropriately for age, converses spontaneously
Euthymic mood, appropriate affect, no hallucinations, illusions or delusions
Mental Status Exam
Good fund of information, concentration, calculation, insight and judgment
Calculations intact

Cranial Nerves – Listed below are normal findings, change as needed

CN I (Olfactory) Absence of nasal obstruction, identification of substance (intact olfactory sense)
Visual acuity: 20/20 OU
No visual field cuts by confrontation
CN II (Optic)
Pupils 3mm EBRTL, intact direct and consensual light reflex
Fundoscopy findings: (+) red orange reflex, clear media, distinct disc borders, no papilledema
CN III, IV, VI
Primary gaze midline, symmetrical eyes, and no observable ptosis
(Oculomotor, Trochlear,
Follows 6 cardinal gazes with good accommodation, no extraocular muscle paresis and palsies
Abducens)
Intact sensation to pinprick, light touch on V1-V3, good masseter and lateral pterygoids tone,
CN V (Trigeminal)
brisk corneal reflex
CN VII (Facial) Symmetrical facial expression (no facial palsy), no ageusia (can identify substance correctly)
CN VIII No gross hearing defects. Air conduction > bone conduction in both ears. No lateralization in
(Vestibulocochlear) both ears
CN IX, X
(Glossopharyngeal and Good gutturals, equal palatal elevation, no dysphonia, intact gag reflex
Vagus)
CN XI (Spinal Accessory) Intact sternocleidomastoid and trapezius strength
CN XII (Hypoglossal) Tongue midline on protrusion, no fasciculations

Motor Exam – Listed below are normal findings, change as needed

Upper and lower
No atrophy, hypertrophy, asymmetry, joint contractures, fasciculations, involuntary movements
extremities (Inspection,
No spasticity, rigidity, flaccidity
tone, range of motion,
No subtle weakness
strength)
Guide:
0/5 No movement

1/5 Flicker of contraction

2/5 Movement, eliminated gravity

Manual Motor Testing
3/5 Full ROM against gravity, not against resistance

4/5 Moves against resistance, but weak

5/5 Normal strength

Muscle group R L Muscle group (LE) R L

(UE)

Shoulder /5 Hip flexion

abduction

Shoulder Hip extension

adduction

Elbow flexion Hip abduction

Elbow extension Hip adduction

Wrist flexion Knee flexion

Wrist extension Knee extension

Finger flexion Foot dorsiflexion

Finger extension Foot plantarflexion

Finger abduction Foot inversion

Finger adduction Foot eversion

Toe extension
Reflexes
Muscle
Check for biceps, brachioradialis, triceps, knee, ankle reflexes
stretch
Abnormal (-) Clonus, (-) Tromner, (-) Hoffman, (-) Babinski (flexor response)
reflexes If needed, check: Chaddock, Schaffer, Gordon, Oppenheim
0/5 Absent (areflexia)

+/- Present only with reinforcement (Jendrassik

maneuver)

1+ Hypoactive

2+ Normal

3+ Hyperactive

4+ Hyperactive with unsustained clonus

5+ Sustained clonus

Cerebellar – Listed below are normal findings, change as needed

Normal rate and rhythm, fluent, no dysphonia, no dysarthria (slowness, slurring of words,
Speech
scanning speech)
Eye movements No nystagmus
No dysmetria, no intentional tremors
Finger-to-nose test
Able to smoothly trace a straight line from the nose to the examiner’s fingertip
Wrist slapping test No overshooting, no arm oscillation, no pronator drift
No overshooting
Arm pulling test
Arm flies upward by a small distance, rebounds, and quickly resumes resting position
No dysdiadochokinesia
Thigh slapping test
Consistent hand movements and comparable with that of examiner
No dysmetria
Heel to shin
Heel does not fall off the opposite knee or shin
Posture, stance, and
No truncal ataxia, normal standing and sitting posture, normal tandem walk and gairt
gait
Sensory – Listed below are normal findings, change as needed
Intact pain sensation on both UE and LE
Pain, temperature Able to sense pain and temperature stimulus symmetrically and proximal vs distal, correctly
responds whether a stimulus is being applied or not
Intact light touch sensation on both UE and LE
Light touch Able to sense light touch symmetrically and proximal vs distal, correctly responds whether a
stimulus is being applied or not
Intact vibration sensation on both UE and LE
Vibration Able to sense vibration symmetrically and proximal vs distal, able to tell when the vibration
stops
Intact position sense on both UE and LE
Position sense
Able to tell all the position the 4th digit is in
Normal Romberg test
Romberg test
Steady and did not fall over

Meningeals – Listed below are normal findings, change as needed

Nuchal rigidity Patient/examiner can flex the neck
Brudzinki’s sign No adduction/flexion of the hip/knee while testing for nuchal rigidity
Patient does not wince with pain upon straightening the knee
Kernig’s sign
No reflex hamstring spasm preventing further straightening of the knee