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KLPR
MEDICAL HEALTH EXAMINATION FORM Date: ________ Time: _____
Name: ________________________________ Age: ___ Gender: ___ Civil Status: ________ Nationality: __________
Religion:_____________ Occupation: _______________ Place of Birth: ______________ Date of Birth: __________
Current Address: _____________________________ # of admission/consultation: ___ Date/Time of adm.: __________
Informant: _____________________ %Reliability: ___ Preceptor: ______________ Date of Submission: __________

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

Indicate Family member and specify conditions/diseases:

Hypertension: ___________________________________
Diabetes Mellitus: _______________________________
Cerebrovascular Accident: ________________________
Obesity: _______________________________________
Tuberculosis (specify): ___________________________
Malignancies (specify): __________________________
Heart Problems (specify): _________________________
Coronary Artery Disease: _________________________
Congestive Heart Failure: _________________________
Rheumatic Heart Disease: _________________________
Thyroid Disorders (specify): ______________________
Liver Cirrhosis: _________________________________
Renal Failure: __________________________________
Gout: _________________________________________
Asthma: _______________________________________
Seizure Disorder: _______________________________
Chromosomal abnormality: _______________________
Hematologic Disorder: ___________________________
Congenital Defect: ______________________________
Psychiatric Disorder: ____________________________
Sudden Death: _________________________________
Others: ___________________________________________
Remarks: _______________________________________

PERSONAL and SOCIAL HISTORY

PAST MEDICAL HISTORY
Childhood Illnesses: ______________________________
________________________________________________
Childhood Immunizations: __________________________
________________________________________________
Adult Illnesses: __________________________________
________________________________________________
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Adult Immunizations: ______________________________
________________________________________________
Previous Hospitalizations/Surgeries: None
Yes
________________________________________________
________________________________________________
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Allergies: _______________________________________
Blood Transfusion/s: None Yes: _________________
________________________________________________
________________________________________________
Medications: ____________________________________
________________________________________________
________________________________________________

FAMILY HEALTH HISTORY
Age, Health Status, Deceased (Cause), etc
Father: __________________________________________
Mother: _________________________________________
Siblings: ________________________________________
________________________________________________
Relatives: _______________________________________

Educ. Attainment and Economic Background: _______
________________________________________________
Work Experience/Condition/Hazards: _______________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
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Cigarette Use: No Yes, Pack Years: ______________
Sticks per Day: ________ Since When?: ____________
Second-hand Smoke: No Yes, ___________________
Alcohol Use: No Yes, type of beverage: ___________
Frequency: _________ Since When?: ______________
Substance Abuse:
, specify: ________________
________________________________________________
Use of Stimulants: ________________________________
________________________________________________
Interests/Lifestyle/Exercise: ________________________
________________________________________________
________________________________________________
________________________________________________
Sleep Pattern/Naps: _______________________________
________________________________________________
Food Preferences: ________________________________
________________________________________________
Housing Conditions: Type of House: _________________
Size: _________________ # of residents: _____________
# of Windows: __________ # of bedrooms: ____________
Source of Ventilation: ______________________________
Home Environment: ______________________________
________________________________________________
Home Vectors: ___________________________________
Water Supply: ___________________________________
Toilet and Sewage: _______________________________
Garbage Disposal: ________________________________
Others: _________________________________________

edema. body weakness. palpable lymph nodes and other important details on the diagram. fractures. specify: ____________ _______________________________________________ OB Surgeries: ____________________________________ GYNECOLOGIC HISTORY: ______________________ ________________________________________________ Remarks : _______________________________________ REVIEW OF SYSTEMS General fever chills malaise fatigability weight change Remarks: ______________________________________ Integumentary pruritus pigmentation/texture change lesions/sores Remarks: ______________________________________ Head and Neck headache dizziness syncope blurring of vision diplopia photophobia eye pain hearing loss ear discharge ear pain tinnitus vertigo nasal obstruction epistaxis hoarseness sore throat disturbance of taste Remarks: ______________________________________ Respiratory dyspnea chest pain hemoptysis cough back pain Remarks: ______________________________________ Cardiovascular chest pain palpitation PND orthopnea easy fatigability shortness of breath Remarks: ______________________________________ Gastro-Intestinal poor appetite dysphagia odynophagia nausea vomiting hematemesis abdominal enlargement Bowel Elimination: Regular: ___________ Irregular: ______________ diarrhea constipation abdominal pain flatulence steatorrhea melena hematochezia Remarks: ______________________________________ Body Built: _____________________________________ Level of Consciousness Awake and Alert Conscious Coherent Lethargic Obtunded Stuporous Comatose Best Response: _________________________________ Mood or Affect Calm Apathetic Anxious Depressed Sedated Combative Paranoid Oriented to: time place person Speech Clear Incomprehensible Slurred Aphasic With difficulty Mute Speech delay Remarks: _____________________________________ Motor Status Ambulatory Plegia: ( )Right ( )Left Paresis: ( )Right ( )Left Gait: __________________________________________ Posture: _______________________________________ Grooming: _____________________________________ In Cardio-Pulmonary Distress?: No Yes VITAL SIGNS and ANTHROPOMETRIC MEASUREMENTS Supine Sitting Standing B. Others: __________ Presence of hair: ______________ Capillary Refill: ___sec Remarks : __________________________________ . deformities/ abnormalities. L: L: L: B. identifying marks.P.Page 2 of 4 OB. R: R: R: CR: ___________ bpm RR: __________ cpm PR: ___________ bpm Temp: ________ °C °F Weight: _____ kg lbs Height: ____ ft cm inch Waist Circumference: _____ cm inch BMI: ________ REMARKS: _____________________________________ INTEGUMENTARY (Please note/describe/ mark noted skin lesions.GYNE HISTORY MENSTRUAL HISTORY: Menarche Age: _____ (flow): _______________________ ________________________________________________ Menstrual Cycle: Menopause Interval: _______________ Duration: ______________ Amount: _______________________________________ Amenorrhea Dysmenorrhea Menorrhagia Menopause Galactorrhea Remarks: ________________________________________ OBSTETRICAL HISTORY: LMP: __________________ OB SCORE: Gravida: ____ Parity:_____ Term: _____ Preterm: ____ Abortion: ____ Living: ____ G1 G2 G3 G4 G5 G6 G7 Sex Date of Delivery Full-term/ Pre-term Genitourinary Dysuria Anuria Polyuria Oliguria Hematuria Incontinence Dribbling Urinary Frequency flank/suprapubic pain passage of stone discharge discharges Remarks: ____________________________ Musculoskeletal muscle pain joint pain & Stiffness swelling bone deformity weakness atrophy contractures restriction of motion Remarks: ______________________________________ Neuropsychiatric syncope seizures weakness or paralysis headache tremors loss of memory depression delirium hallucination Remarks: __________________________ Endocrine weight change heat or cold intolerance polyuria polydypsia polyphagia abnormal growth Remarks: ______________________________________ Hematologic easy bruisability easy fatigability pallor Remarks: ______________________________________ ======PHYSICAL EXAMINATION======= Type of Delivery GENERAL SURVEY Personin-charge Place of Delivery Condition at Birth Use of Contraceptives: No Yes.) Color: ________________ Texture: _________________________________________ Lesions: _________________________________________ Nailbeds: no clubbing no swelling.P.

Grade: ____________ Posterior Pharynx: ________________________________ Other Remarks: ___________________________________ Neck Skin: ____________________________________________ Architecture: _____________________________________ Muscle Tone: _____________________________________ Trachea: intact and in midline with deviation: ________ Lymph nodes: non palpable palpable: _____________ Thyroid Gland: not visibly enlarged enlarged Remarks: ______________________________________ CHEST and LUNGS HEAD. Loud at: ____________ S2. etc dental condition: ________________________________ Thorax: Normal/Elliptical Funnel Chest Barrel Chest Pigeon Chest Flail Chest A:P Ratio: _______ Remarks: ______________________________________ Chest Expansion: Symmetrical Asymmetrical Chest Lagging IC Retractions/Bulging Remarks: ______________________________________ Breathing Even Uneven Orthopneic: # of pillows: _______ Labored Dyspneic Shallow Deep Use of Oxygen via: _____________________________ Remarks: _______________________________________ Tactile Fremitus: Increase/Decrease:_____________________ Others: subq. EYES. crepitus tenderness Remarks: ______________________________________ Percussion: Resonant Hyper-resonant Dull Flat Remarks: ______________________________________ Breath Sounds Normal Crackles/Rales Rhonchi Stridor Wheezes Remarks: ____________________________ whispered pectoriloquy Remarks: ______________________________________ Breast: Symmetrical Asymmetrical ulceration Findings: ______________________________________ ______________________________________________ Nipples: discoloration scaling discharge depression/flattening ulceration Remarks: ______________________________________ Other Remarks: _________________________________ CARDIOVASCULAR JVP: ____ cm sternum R.Page 3 of 4 Oral mucosa: moist dry with lesions: __________ Gingiva: moist dry with lesions: ________________ Tongue: with deviation: _________ with lesions: _________________________________ Uvula: midline ation/s: ______________________ Tonsils: not inflamed inflamed.5 cm Displaced: ___________________________________ Palpation: Thrust Heaves Lifts Cardiac Auscultation regular Irregular: ___________________________ weak bounding with Pacemaker: ______________________________ S1.atrium Degree angle:______° Jugular Vein: : _____________ Carotid: ___________________ No Bruit W ith Bruit Precordium: Adynamic Dynamic: _________________ Ectopic Pulsations: none present: _________________ Apex Beat: 5th ICS Left MCL <2.5cm >2. Loud at:____________ S3: ___________________ S4: ___________________ Cardiac Murmurs: _______________________________ ______________________________________________ ______________________________________________ Other Findings: _________________________________ ______________________________________________ . EARS. NOSE and THROAT Head Normo Micro with lumps/depressions/tenderness Temporal Artery: palpable non-palpable Others: _________________________________________ Hair and Scalp evenly distributed receding hairline bald alopecia smooth dry with areas of scaliness/lumps/lesions: _______________ Remarks: _______________________________________ Face Symmetrical facial movement asymmetrical movements involuntary movements Lesions: __________________ Deformities: none present: _______________________ Remarks: ______________________________________ Eyes Eyebrows:color_____________ distribution_____________ Eyelids: Eyelashes: _______________________________________ Sclera: white icteric/ jaundice Others: ____________ Conjunctiva: pink pale reddened with lesions Cornea: opacities etc: ____________ Iris: color/contour: ________________________________ Pupil: brisk sluggish pinpoint fixed dilated non reactive non delineated Pupil Size: R: _____ mm L: ______ mm Use of corrective lenses/glasses: No Yes: __________ Visual Acuity: ____________________________________ Visual Field: _____________________________________ Fundoscopic Exam: ________________________________ Other Remarks: ___________________________________ Ears Outer ear aligned with outer canthus of the eye ears symmetrical assymetrical: __________________ discharge: ___________________________________ Pain (auricles/mastoid): none present: ______________ Auditory Canal: __________________________________ _______________________________________________ Otoscopic Exam: __________________________________ _______________________________________________ Hearing Tests: ___________________________________ _______________________________________________ Other Remarks: ___________________________________ Nose Symmetrical Septum intact and in midline No discharge With discharge: specify: ___________ Rhinoscopy: _______________________________________ Paranasal Sinuses: non tender tender: ______________ Other Remarks: ___________________________________ Oral Cavity Lips: moist dry with lesions: ________________ Teeth: complete: _____ incomplete dentures.

Ulna: palpable others: ___________________ Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Motion: FROM restricted with pain o/little mov’t OTHERS: ________________________________________ Arms and Shoulders: symmetrical uneven: __________ Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Motion: FROM restricted with pain o/little mov’t OTHERS: ________________________________________ Spine: Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Motion: FROM restricted with pain o/little mov’t OTHERS: ________________________________________ Hips and Thighs: Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Motion: FROM restricted with pain o/little mov’t OTHERS: ______________________________________ Knee: Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Crepitus: none present: ________________________ Motion: FROM restricted with pain o/little mov’t OTHERS: ______________________________________ Ankle and Feet: Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Crepitus: none present: ________________________ Motion: FROM restricted with pain o/little mov’t OTHERS: ______________________________________ Toes and Soles: Nodules/Pain/Swelling:____________________________ Atrophy/Hypertrophy: none present: ______________ Motion: FROM restricted with pain o/little mov’t OTHERS: ______________________________________ NEUROLOGIC EXAMINATION Cerebrum: Level of Consciousness Awake and Alert Conscious Coherent Lethargic Obtunded Stuporous Comatose Best Response: _________________________________ Mood or Affect Calm Apathetic Anxious Depressed Sedated Combative Paranoid Follows simple commands: Yes No Oriented to: time place person Intact Memory: Can Do: simple math calculations abstract thinking appropriate moral judgment Cerebellum: Posture: _________________________________________ Tremors: one present Able to do: Finger-to-Nose Test Rapid alternating mov’t Heel-to-shin Test Rhomberg’s Test: negative positive OTHERS:________________________________________ CN ASSESSMENT FINDINGS I II II. specify: ______________________________ Visible Pulsations: ___________________ Visible Peristalsis: ___________________ Umbilicus: inverted everted Bowel Sounds: _______ per minute at: RLQ Normal Hyperactive Hypoactive Absent Bruits: _____________________________ Area of Tympanism: RLQ RUQ LUQ LLQ Area of Dullness: RLQ RUQ LUQ LLQ LIVER Liver Span: _______cm MCL or _______cm MSL Liver Tenderness: _________________ Remarks: ______________________________________ SPLEEN Traube’s Space: tympanitic dull Spleenic Tenderness: ______________ Remarks: ______________________________________ KIDNEY non palpable palpable: ________________________ CVA Tenderness: : ____________ Remarks: ______________________________________ Tone: Soft Firm Rigid/Board-like Tender Other Remarks: ___________________________________ Palpable Mass: _____________________ Other Remarks: ___________________________________ Other Palpable Organs: __________________________ Remarks: ______________________________________ -----------------SPECIAL EXAMINATIONS-------------------M urphy’s Sign Direct Tenderness Blumberg Sign M arkle Sign Rovsing’s Sign Psoas Sign Obturator Sign Cutaneous Hyperesthesia and Allodynia Subcutaneous crepitus Bulging Flanks Shifting Dullness Fluid Wave Puddle Sign Ruler Test EXTREMITIES Hands. III III. IV. Hypothenar: Nodules/Pain/Swelling: PIP __________ Deviation: one ulnar radial others: ____________ Motion: FROM restricted with pain o/little mov’t OTHERS: ________________________________________ Forearm and Elbow: symmetrical uneven: __________ Radius. VI V V. VII VII VIII IX. wrists and fingers: Thenar. X XI XII Motor Exam Symmetrical Movements: Atrophy: Fasciculations: Muscle Strength: RUE____ RLE____ LUE____ LLE____ OTHERS:________________________________________ Sensory Exam Intact Sensory: stereognosia graphestesia Sensory Test: RUE____ RLE____ LUE____ LLE____ OTHERS:________________________________________ Reflexes DTR: intact symmetrical brisk normoreflexia Babinski: RUE____ RLE____ LUE____ LLE____ Meningeal Exam Nuchal Rigidity Brudzinski Sign Kernig Sign ----------------------------------------------------------by: KLPR .Page 4 of 4 ABDOMEN Contour: Flat Globular Scaphoid Protuberant Symmetry: ______________________________________ Skin Findings: striae scars spider angioma dilated vessels visible mass Remarks: _____________________________________ Colostomy.