ROTATION

DATE AND TIME

PLACE OF INTERVIEW
I. GENERAL INFORMATION
NAME
MARITAL STATUS
DATE OF ADMISSION
ADDRESS
SOURCE OF INFORMATION

II. CHIEF COMPLAINT

P

Precipatating?

Quality?

Relief?

Accompanying symptoms?

Timing?

III. HISTORY OF PRESENT ILLNESS

DAYS/WEEKS PTA

COMPLAINTS

IV. PAST MEDICAL HISTORY

CHILDHOOD ILLNESSES
IMMUNIZATIONS
ADULTILLNESSES
MEDICATIONS (DRUG, DOSAGE, PURPOSE)
ALLERGIES
SRUGERIES
V. PERSONAL AND SOCIAL HISTORY
SMOKER?

Age started? Pack years?

ALCOHOLIC DRINKER?

Age started? How often? No. bottles per day? Kind of alcohol?

ILLICIT DRUG USE

Age started? What kind of drug? How often?

OCCUPATION
EDUCATIONAL ATTAINMENT
HOUSE ENVIRONMENT

living with? How many rooms? Ventilation?

WATER SOURCE
GRABAGE COLLECTION
FOOD SOURCE
DIET

typical meal? favorite food?

HABITS

coffee?

VI. FAMILY HISTORY

FAMILY MEMBER

CAD

VII. OBSTETRIC AND GYNECOLOGICAL HISTORY

OB SCORE

G P( F PAL)
PREGNANCY

YEAR

MENARCH
MENSTRUATION

Regular? No. days per monthly cycle? No. bleeding days? No. pads/day, presence of symptoms?

SEXUAL HISTORY

Had STD before? Sex with domestic sex workers?

AGE FIRST SEX

CONTRACEPTION

Method? How many years? Reason for changing/stopping?

NO. OF SEXUAL PARTNERS

At present? Entire life?

VIII. REVIEW OF SYSTEMS

GENERAL
Weight Loss/Gain

Napansing pagbabago sa timbang

Fatigue

palaging pagod

Fever

lagnat

Chills
Trouble Sleeping
SKIN
Rashes
Lumps
Itching
Dryness
Color Changes
Hair and nail changes
HEENT
Headache
Head Injury
Neck Pain
Decreased hearing
Ear Discharge
Ringing in ears
Earache
Vision Loss/Changes
Eye pain
Eye redness
Blurry/double vision
Flashing lights
Specks
Nose Stuffiness

hirap sa pagtulog

Nose Discharge
Nosebleeds
Sinus pain
Dentures
Sore tongue
Sore throat
Dry mouth
Hoarseness
Thrush
Non-healing sores
Neck Lumps
Swollen glands
Neck pain
Neck stiffness
IX. PHYSICAL EXAMINATION
A. GENERAL SURVEY
APPARENT STATE OF HEALTH
LEVEL OF CONSCIOUSNESS
SIGNS OF DISTRESS
BUILT, BODY SYMMETRY AND POSTURE
HEIGHT
BMI
B. VITAL SIGNS
BP
HR
C. HEENT
HEAD
EYES

VISUAL ACUITY
VISUAL FIELD (CONFRONTATION)
POSITION ALIGNMENT OF EYES
EYEBROWS
EYELIDS
LACRIMAL APPARATUS
CONJUNCTIVA & SCLERA
CORNEA & LENS
IRIS
PUPILS
EXTRAOCULAR MUSCLES

OPHTHALMOSCOPIC EXAM

EARS

AURICLE
EAR CANAL AND DRUM

AUDITORY ACUITY
AIR AND BONE CONDUCTION
LATERALIZATION
NOSE AND PARANASAL SINUSES

I: Anterior and Inferior surfaces of the nose

Test for Nasal obstruction
I: inside of nose
NASAL SEPTUM
Abnormalities: ulcers and polyps
Sinus Tenderness

MOUTH AND PHARYNX

LIPS
ORAL MUCOSA
GUMS AND TEETH
ROOF OF MOUTH
TONGUE AND FLOOR OF MOUTH
PHARYNX

AGE
GENDER
RELIGION
DATE OF BIRTH
RELIABILITY

CHARACTER

HTN

ASTHMA

AGE

MANNER OF DELIVERY

LMP

MENOPAUSE

No. pads/day, presence of symptoms?

BREAST
Lumps
Pain
Discharge
Dimpling
Change in color
RESPIRATORY
Cough
Sputum
Coughing up blood
Shortness of Breath
Wheezing
Painful breathing
CARDIOVASCULAR
Chest pain/discomfort
Chest tightness
Palpitations
Difficulty of breathing
Swelling
PND
SOB with activity
DOB while lying down
GASTROINTESTINAL
Swallowing dificulties
Heartburn
Chang in appetite
Nausea
Change in Bowel

Rectal Bleeding
Caonstipation
Diarrhea
Yellow eyes or skin
URINARY
Frequency
Urgency
Burnng/pain
Blood in urine
Incontinence
Change in urinary strength
VASCULAR
Calf pain with walking
Leg Cramping
NORMAL

WIEGHT

RR
TEMPERATURE

I: shape and symmetry

Pupillary Reaction To Light
I: reflections in corneas
Cover-Uncover Test
Extraocular movements

Conjugate movements, deviations, nystagmus, lid lag

Convergence
I: Optic Disc

sharpness or clarity of disc outline

color of disc
size of central physiologic cap
presence of venous pulsations
comparative symmetry of eyes

I: Retina

arteries, veins, AV crossings, fovae and macula

lesions

I: Deformities, lumps and skin lesions

TUG TEST
I: Ear canal, eardrum, handle of malleus, short and long process of malleus

RHINNE'S TEST
WEBER TEST
Assymetry, deformity
Nasal mucosa: swelling, bleeding and exudate
deviation, inflammation, porforation

color, moisture, lumps, ulcers, cracking or scaliness

color, ulcers, white patches and nodules
color of gums
teeth: any missing, discolored, mishappen or abnormally positioned
colora= & architechture of hard palate
symmetry of tongue
I: color and texture of dorsum and undersides of tongue
I: soft palate, anterior and posterior pillars, uvula, tonsils and pharynx
color and symmetry
exudate, swelling ulceration & tonsilar enlargement

CANCER

DM

PLACE

OUTCOME

MUSCULOSKELETAL
Muscle Pain
Joint Pain
Stiffness
Back Pain
Redness of Joints
Swelling of Joints
Trauma
NEUROLOGIC
Dizziness
Fainting
Seizures
Weakness
Numbness
Tingling
Tremor
HEMATOLOGIC
Ease of bruising
Ease of bleeding
ENDOCRINE
Heat or cold intolerance
Sweating
Frequent urination
Thirst
Change in appetite
PSYCHIATRIC
Nervousness
Stress

LIVER DX

OTHERS

COMPLICATIONS/NOTES

NOTES

Depression
Memory Loss

vements, deviations, nystagmus, lid lag

clarity of disc outline

, AV crossings, fovae and macula