PATIENT PROFILE

Date of Interview:________________________________________
Ward:__________________________________________________
Admission Date:_________________________________________
Source and Reliability:____________________________________

Life History
Name:____________________________________________
Sex:

male

female

Age:_______________________

Birthdate:_______________________________

Address:________________________________________________________________
No. of years residing:______________________________________________________
Previous address:____________________________________________________________
Reason for transfer:__________________________________________________________
Birthplace/Place of origin:______________________________________________________
Religion:__________________________________________
Educational Attainment: Elementary

undergraduate graduate

High School undergraduate graduate
 College

undergraduate graduate

Course:_______________________

Others:______________________________________________
Civil Status:

single

married/living with partner

divorced

widowed

Years married: _______________________________

Occupation and Employment History
Present work:________________________________________ For how many years:__________________
Previous work:_______________________________________ For how many years:__________________
Income:__________________________________________________________
Source of income (aside from work):___________________________________
Usual Expenses:___________________________________________________

Living Environment
Family Composition/Position in the family: ______________________________________
Living with who/whom: _____________________________________________________
Number of rooms:_____________________

# of storey: 1 floor

2 floors

3 floors

others:______

How many people in the house:__________________________________________
Type of house: wood

concrete

Water supply (for drinking):

Nawasa

others:
water station/mineral water

deep well

Garbage disposal: collected by a truck, how often:________________________________________
burned
compost pit

others: _________________________________

Habits and Description of average day Hobbies and interest: _________________________________________________________________________ Health Practices: ____________________________________________________________________________ good eats less no appetite After illness/at present: good eats less no appetite Appetite before illness: Favorite food:_______________________________________________________________________________ Religious Restrictions:________________________________________________________________________ Diet/restrictions:_____________________________________________________________________________ How many hours of sleep per day (usual):_________________________________________________________ Quality of sleep: good wakes at the middle of the night Problem falling asleep: yes no Routine before sleeping: drinking milk difficult initiating sleep after waking up exercising/working out others:________________________ Exercise: yes no How often (per week): once twice thrice everyday every weekend occasional What kind of exercise: jogging stretching working out cardio workout gym running others:______________________________________ Bowel movement: everyday every other day 3x a week Usual color of stool: black yellowish greenish brown watery with blood (gross) Characteristics of stool: hard aerobics others: Urinary Frequency (estimated number of urination a day):____________________________________________ Characteristics: yellowish clear dark yellow with pain during urination without pain during urination nocturia difficulty in initiating urination with blood others:______________________________________________ Use of tobacco/smoking: yes no Since when:_________________________________________________ How many sticks/day:_________________________________________ Alcohol Intake: yes no When: everyday twice a week thrice a week occasional How much:_____________________________________________________ Caffeine intake: yes no How often: everyday twice a week thrice a week others: .

Associated Symptoms . Timing.Illegal drug Intake: yes no What drug:_________________________________________________ How much:_________________________________________________ Current Medications (taken at home) Drug Dose/Route Frequency Duration CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: **Character. Alleviating & Relieving Factors. Location & Radiation. Intensity or Severity.

.

Childhood disease Age illness was acquired Treatment/Regimen done Chicken pox Measles Mumps Tuberculosis Malaria Dengue Influenza Gastroenteritis 2. Surgeries/Hospitalization Hospital Procedure/Diagnosis Date of confinement/ Length of stay .PAST HEALTH MAINTENANCE HISTORY 1. Allergies Food:___________________________________________________________________________ Drugs/Medications:________________________________________________________________ Clothes:_________________________________________________________________________ Environment:_____________________________________________________________________ 3.

Accidents Hospital Date of confinement/ Length of stay Diagnosis Treatment/Work ups . Immunization complete incomplete cannot recall Date Given Number of dose received BCG Hepatitis B OPV MMR DPT Tetanus Toxoid 5. Major Illness Illness/disease Diagnosed when/since when 6.4.

Obstetric History  Gravida ____ Parity ____ (Term____ Preterm ____ Abortion ____ Living ____) Delivery of the Baby Year (Planned or Not?) Living/ Abortion  Duration of Pregnancy (term/preterm) Hrs. of Labor Manner of delivery (if CS.7. periods start every: _________________days  If your menstrual periods are irregular. is it: yes before menses yes no no during menses both  Last Menstrual Period: __________________________________________________________  Post-menopausal Bleeding: yes no 8. state reason) Child Where and assisted by whom Feto-maternal complication Sex Birth weight Present Health Family Planning Methods Pills Brand:_______________________ # of years used:___________________ Brand:_______________________ # of years used:___________________ Condom Withdrawal Injection Duration of effect:________________________________________ Calendar method Bilateral tubal ligation Vasectomy Others:__________________________________________________________________ . Menstrual History  Menarche: ____________________________________________________________________  If your menstrual periods are regular. periods start every: _______ to _______days  Duration of bleeding: _________ days  Interval between menstruation:____________________________________________________  Amount of bleeding (how many pads): ______________________________________________  Does bleeding or spotting occur between periods?  Is pain associated with periods? If yes.

Severe Headaches. Vaginal bleeding. Regular contractions. Blurry Vision. Fever. Date of Prenatal Check-up Prenatal Summary Maternal Weight Danger Signs of Pregnancy Blood Pressure Pelvic/Cervical Examination Fetal Movement Fundal Height (cm) Fetal Heart Rate Fetal Position (Leopold’s Maneuver) **Danger Signs: N/V. Pelvic/Abdominal pain  How was the pregnancy confirmed? _______________________________________________________  Assessment (Date and Time taken:__________________________________________) o Height_______________ Weight_____________ BMI____________ o Temperature __________HR ________________ BP ____________ RR___________ o Fundic height:___________cm o Leopold’s Maneuver/Fetal Position:__________________________________________ 9. Gynecological History  Infection: UTI PICOS Endometriosis Venereal Warts Genital Herpes others:__________________________________________________________  If yes. Swelling of the head or face. Persistent back pain. Sexual History  Age of first contact/sex:__________________________________________________________  Number of partners:_____________________________________________________________  Frequency of sex/contact (per week):_______________________________________________  Signs and symptoms associated during/after contact or sex: pain during intercourse post coital bleeding others:_________________________ . Diarrhea. Gush of fluid from vagina. when and how was it treated?_______________________________________________________ 10.

FAMILY HISTORY Name Age Postition in the Family Illness .

Throat. of pregnancies___ Complications___ Live Births___ Heaviest Baby ___lbs PID___ Breast Nipples___ Lump___ Pain___ Discharge___ Extremities Cyanosis___ Clubbing___ Edema___ Varicosity___ Ulcers___ Claudication___ Hematopoietic System Excessive bleeding/bruising___ Anemia___ Pica___ Nervous System Headache___ Tremor___ Fainting Spells___ Seizures___ Dizziness/Vertigo___ Head Trauma___ Sensory perversions___ Movement problems ___ Language/learning problem ___ MusculoSkeletal Joint Stiffness___ Pain___ Swelling___ Muscle Weakness___ Endocrine System Heat/Cold Intolerance___ Thyroid Problems___ Neck Surgery/Irridiation___ DM Indicators___ Psychiatric Mood Swings___ Behavioral Changes___ Anxiety___ Depression___ . Mouth Nasal Obstruction___ Discharge___ Abnormal Olfaction/Anosmia___ Epistaxis___ Frequent colds/cough___ Dysphagia___ Odynophagia___ Change in Voice___ Neck Mass___ Toothache___ Dental Caries___ Gum Bleeding___ Ulceration___ Congenital Deformities___ Respiratory Cough/Sputum___ Difficulty of Breathing___ Wheezing (Asthma)___ PTB Exposure___ Hemoptysis___ Cardiovascular Palpitation___ Syncope___ Chest pain___ Edema___ Hypertension___ Orthopnea___ Dyspnea___ Gastrointestinal Dysphagia___ Nausea___ Vomiting___ Appetite___ Abdominal Pain___ Melena___ Jaundice___ Bleeding___ Indigestion___ Heartburn___ Hematemesis___ Fatty Food Intolerance___ Stool Frequency/Character___ Hemorrhoids___ Abdominal Distention___ Hernia Urinary Pain___ Volume___ Retention___ Bleeding___ Stream___ Polyuria___ Nocturia___ Stones___ Infection___ Hesistancy___ Urgency___ Change in Color___ Frequency___ Dribbling___ GenitoReproductive (Male) Discharge___ Pain___ Libido___ Sexual Difficulties___ GenitoReproductive (Female) Menarche___ LMP___ PMP___ Menses: Regular___ Duration___ Amount___ Post-coital bleeding___ Contraceptive Use___ No.REVIEW OF SYSTEMS General Fever___ Fatigue___ Sweating___ Weight Loss/Gain___ Weakness___ Skin Color___ Texture___ Itching___ Rashes___ Changes in hair/nails___ Eyes Visual Impairment___ Redness___ Tearing___ Pain___ Double Vision___ Discharge___ Trauma___ Ears Hearing Loss___ Otalgia___ Discharge___ Tinnitus___ Nose.

PHYSICAL ASSESSMENT Time/Date Done:___________________________ Vital Signs Temp_________ Radial Pulse_________ Apical Pulse_________ RR_________ BP_________ General Survey Sensorium____________________________________ Distress_______________________________________ Facial Expression/Mood/Affect__________________________________________________________________ Speech/Articulation___________________________________________________________________________ Appears Age Stated______________ Acute or Chronically Ill__________________ Skin Color_______________ Any Physical Deformities______________________________________________________________________ Mobility_______________________ Normal Gait_________________ Needs Assistance___________________ Use of Assistance Device_______________________ What?_________________________________________ Nutritional Status_________________ Weight_____________ Height: ______________ BMI _______________ Hygiene and Grooming________________________________________________________________________ Skin General Color:  Pallor  Jaundice  Flushed  Cyanotic Texture:  Smooth  Rough Others____________________ Turgor:  Good  Fair  Poor Moisture:  Dry  Wet/Clammy  Oily  Ecchymoses  Hematoma Hemorrhages:  Petechiae Location________________________________________________________________ Lesions:______________ Location______________________ Measurement________________ Head Hair:  Fine  Coarse  Dry  Normal Scalp:  Clean  Dandruff  Lice Lesions________________________________ Eyes: Visual acuity __________________(left)  Near-sighted  Far-sighted  Alopecia ___________________(right)  Astigmatism Corrective lens_________________________________________________________________ Conjuctiva____________________________ Sclera___________________________________ Pupils (left) (right) _______mm  Reactive  Consensual Reflex _______mm  Reactive  Consensual Reflex EOM___________________ Nystagmus________________ Visual Fields__________________ Ptosis__________________ Exophthalmos______________ Tension_____________________ Fundoscopy___________________________________________________________________ Ears Lesions of the external ear_____________________________ Location_________________________________ Discharge____________________ Tympanic Membrane____________________ Mastoids_________________ .

Nose Patency______________________ Discharge_________________________ Blockage____________________ Septum_________________________________ Sinus Tenderness____________________________________ Mouth Lips:  Pallor  Cyanosis  Dryness/Cracks Lesions__________________________ Teeth:  Complete  Missing  Dentures  Caries Gums:  Pinkish  Pale  Bleeding  Tenderness Tongue: Uvula Position____________________________ Check Structures: Midline? _____________________ Salivary Glands: _____________________________________________________________________________ Throat:  Enlarged Tonsils  Post-nasal Drip Neck Any CLAD? ________________________________________________________________________________ Thyroid____________________________________________________________________________________ Stiffness______________________________________ Masses_______________________________________ Lymph Nodes_______________________________________________________________________________ Breast Masses_________________________________________ Discharge__________________________________ Chest & Lungs Anterior Thoracic Cage Configuration____________________________________________________________ Posterior Thoracic Cage Configuration____________________________________________________________ Spinous Process________________________________ Percussion___________________________________ Breathing Pattern:  Effortless  Tachypnea Hyperpnea Bradypnea  Dyspnea  Orthopnea Chest Expansion:  Symmetrical Vocal Fremitus:  None  Assymetrical  Egophony  Apnea (right/left)___________  Bronchophony  Whispered Pectoriloquy Tactile Fremitus_____________________________________________________________________________ Percuss Lung Field___________________________________________________________________________ Breath Sounds:  Clear  Equal  Crackles  Wheezes Location________________________________________________________________ Pericordial Area: Heart Sounds:  Flat  Bulging  Normodynamic  Hyperdynamic  Tenderness  Thrill PMI at _______________________________________  S1  S3  S2 Rhythm________________________ Murmur (where?)__________________________ .

Abdomen  Dilated Veins Skin:  Striae  Scars  Rashes Location______________________________________________________________________  Flat  Globular Configuration: Bowel Sound:  Protuberant  Scaphoid  Symmetrical Normal or Hyperactive or Hypoactive *presence of bowel sound per quadrant Abdominal Pain____________________ Location______________________________ Scale_______________ Bruit:  Absent  Present Percussion:  Tympanitic  Hypertympanitic  Fluid Wave Test  Shifting Dullness Test  Muscle Guarding  Direct Tenderness Palpation: Location______________________________________  Dull  Rebound Tenderness Liver______________________________________________________________________________________ Kidney_____________________________________________________________________________________ Spleen_____________________________________________________________________________________ MusculoSkeletal and Extremities Nail:  Pink Joints:  Redness  Pale  Cyanosis  Warmth  Crepitation  Inflammation  Clubbing CRT________ Swelling at __________________________________________________________________________ Tenderness at ________________________________________________________________________ Full ROM ____________________________________________________________________________ Decreased ROM at ____________________________________________________________________ Legs:  Varus  Valgus Gluteal Folds:  Symmetrical  Assymetrical Edema:  None  Non-Pitting  Pitting [ +1 (<2mm) +2 (2-4mm) +3 (5-7mm) +4 (>8mm)] Location is at __________________________________________________________________ Muscle Size:  Equal  Atrophy at _____________________________________________________ Tone:  Normal  Hypertonic MMT Grading System  Flaccid  Fasciculation  Tics  Tremors 5 – move against resistance 4 – move with some resistance 3 – move against gravity not with resistance 2 – move in joint but not against gravity 1 – move but barely detectable or not normal strength .

+1. +2.Peripheral Vascular System (0. +3) Left Pulse Site Right Radial Brachial Femoral Popliteal Dorsalis Pedis Posterior Tibial Neurosensory Level of Consiousness DTR Babinski Balance Strength Sensation Seizure Precaution Stereognosis Extinction Graphesthesia Two Point Discrimination CN 1: __________________________________________ CN 2: __________________________________________ CN 3: __________________________________________ CN 4: ___________________________________________ CN 5: __________________________________________ CN 6: ___________________________________________ CN 7: __________________________________________ CN 8: ___________________________________________ CN 9: __________________________________________ CN 10: __________________________________________ CN 11: _________________________________________ CN 12: __________________________________________ Cerebellar:  fingers-to-nose  Romberg  tandem walk  stand on one foot  rapid hand alternation Deep Tendon Reflex: Biceps:___________________________________ Patellar: ________________________________________ Triceps: __________________________________ Achilles: ________________________________________ Brachioradialis: ____________________________ Cremasteric: ____________________________________ .