Date and time of interview:___________ Date and Time of admission: _______________________

Source of information:__________________________ Reliability:___________________________

Name: _______________________________________ Birthdate: _________________________
Age:___________
Sex: O F O M
Religion:_________
Civil Status: ______
Address: ___________________________
Chief Complaint: _______________________
History of Present Illness:

Onset- gradually? How did it develop? Immediately?

Cause of onset? Happened before? Compare
Location- diffused? Localized? Radiating?
Duration- Constant? Episodic? the same? Worsens?
Character- dull, sharp, aching, gnawing, constricting?
Association- other s/s which appeared at the same time?
Aggravating/Alleviating- what worsens? Lessens?
Treatment- Outcome? Immediate relief?
Severity- rate. Interferes with ADL, work, sleep?

History of Present Illness:

Past Medical History (Adult):

Medical
Current/Past Illness (Comorbidities) _______________________________________
_________________________________________________________
Hospitalizations _______________________________________________________
date and place, diagnosis, days of admission, procedures done, discharge meds

Medications: _________________________________________________________
_________________________________________________________
_________________________________________________________
dosage, frequency, tab/capsule, OTC/prescribed, compliance
Allergies: ___________________________________________________________
Surgical: ____________________________________________________________
Others:

Personal History:
Hometown: _____________________________________________
Education: _____________________________________________
Play: __________________________________________________
Guardian: _______________________________________________
Hygienic practices:_________________________________________
Usual ADLs: _____________________________________________
Usual meal:______________________________________________

How long: _____

# in family:____
# of siblings:___

Family History
Members
Age
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____

Occu./Edu.
____________
____________
____________
____________
____________
____________
____________

Disease/Status (alive) Cause of death (deceased)

___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________

Encircle if (+): DM, Asthma, Psych, CAD, HTN, TB, Cancer, Clotting disorders
Others: __________________________________________________________________

MISCELLANEOUS:

SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL
Recent weight gain;
how much____
Recent weight loss:
how much____
Fatigue
Weakness
Fever
Night sweats

NERVOUS SYSTEM
Headaches

PSYCHIATRIC
Depression

Dizziness

Excessive worries

Fainting
Numbness or tingling
Memory loss

MUSCLE/JOINTS/BONES
Numbness
Joint pain
Muscle weakness
Joint swelling
Where?
EARS
Ringing in ears
Loss of hearing

STOMACH AND INTESTINES

Nausea
Heartburn
Stomach pain
Vomiting
Yellow jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools

EYES
Pain
Redness
Loss of vision
Double or blurred vision
Dryness

SKIN
Redness
Rash
Nodules/bumps
Hair loss
Color changes of hands or feet

Difficulty falling asleep

Difficulty staying asleep
Difficulties w/ sexual arousal
Poor appetite
Food cravings
Frequent crying
Sensitivity
Thoughts of suicide / attempts
Stress
Irritability
Poor concentration
Racing thoughts
Hallucinations
Rapid speech
Guilty thoughts
Paranoia
Mood swings
Anxiety
Risky behavior

THROAT
Frequent sore throats
Hoarseness
Difficulty in swallowing
Pain in jaw

BLOOD
Anemia
Clots

HEART AND LUNGS

Chest pain
Palpitations
Shortness of breath
Fainting
Swollen legs or feet
Cough

KIDNEY/URINE/BLADDER
Frequent or painful urination
Blood in urine
Women Only:
Abnormal Pap smear
Irregular periods
Bleeding between periods
PMS

OTHER PROBLEMS:

Neuro Exam
I.
1. GCS
2. Higher Cerebral Function
MMSE

a. Memory
b. Emotional (normal, anxiety, uninhibited behavior, slowness
of response, apathy, depression)
c. Reasoning
d. Cognitive
-language lattern (fluent/hesitant), name object, understand spoken commands,
read correctly, write correctly, recognize object, numerical calculation, copy
geometric pattern

II. Cranial Nerve Examination

CN I (Olfactory):
CN II (Optic):
Visual acuity:
Visual fields:

Pupils:

CN III, IV, & VI (Occulomotor, Trochlear, and Abducens):

S, M and I rectus and Middle Oblique:
L Rectus:

S Oblique:

CN V (Trigeminal):
Pain, temperature, light touch:
Corneal reflex:
Jaw jerkL

CN VII (Facial):
Eye closure, flattening of nasolabial fold, asymmetry
Wrinkle forehead (frontalis)______, Close eyes while opening (Orbicularis
oculi)_______,
Purse lip
(Buccinator), Show teeth (Orbicularis oris)

CN VIII (Vestibulocochlear):
Webers and Rinnes

CN IX & X (Glossopharyngeal & Vagus)

M-L-K testing:
Ah and gag reflex:

CN XI (Accessory):
Turn head (Sternomastoid)
Shrug (Trapezius)

CN XII (Hypoglossal):
Inspect tongue:

III. Upper Limbs

Motor

A. Appearance:
Wasting_________ Fasciculations_____________

B. Tone:
C. Sensation:
D. Power:
Closed eyes, outstretched arm:

0-no contraction, 1-flicker, 2-active movement gravity eliminated,

3- active against gravity, 4, against gravity and resistance 5normal
Shoulder Abduction (C5,C6- Axillary Nerve- Deltoid)
Elbow extension supinated (C5,C6- Musculocutaneous- Biceps)
Elbow extension (C6,7,8- Radial nerve-Triceps)
Elbow extension midposition (C5,6- Radual nerve- Brachioradialis)
Push against wall (C5,6,7- Long thoracic nerve- Serratous Anterior)
Sensation

Pain____________, Light touch____________,

Temperature_______________
Reflexes (clench teeth to enhance)
Biceps Jerk (C5,6, musculocutaneous nerve)
Supinator jerk (C6,7 radial nerve)
Triceps (C6,7,8 radial)
Abdominal (T7-T12)

IV. LOWER LIMBS

Motor
A. Appearance:

Wasting, Assymetry, Hypertrophy, Myokimia

B. Tone:
flex and extend knee joint, sudden ankle flexion with flexed knee

C. Sensation:
D. Power:
0-no contraction, 1-flicker, 2-active movement gravity eliminated,
3- active against gravity, 4, against gravity and resistance 5normal

Hip flexion (L1,2,3- Femoral nerve- Illiopsoas)

Hip extention (L5, S1, S2- I Gluteal nerve- Gluteus maximus)
Hip abduction (L4, L5, S1- S fluteal nerve- G medius, minimus, fascia latae)
Hip abduction (L2,3,4 Obturator nerve adductors)
Knee flexion (L5, S1,2- Sciatic nerve-Hamstring)

Knee extension (L2,3,4- Femoral nerve- Quadriceps)

Dorsiflexion (L4,L5- Deep Peroneal nerve-Tibialis Anterior)
Plantar Flexion (S1,2- Tibial nerve- Gastrocnemius)

Sensation

Pain____________, Light touch____________,

Temperature_______________
Reflexes (pull clasped hands apart to enhanceJendrassiks maneuver)
Knee jerk (L2,3,4)
Ankle Jerk: (S1,2)
Plantar Response
Babinski_____, Chaddocks _______
V. Cerebellar Function

Finger to nose ________heel to shin ________rapid

alternating movement tests___________ Gait___________
VI.

Meningeal Signs