HISTORY AND PHYSICAL EXAMINATION

Date of Interview: ______________________________

Time of History: _______________________________
Informant: ____________________________________
Relationship to the Patient: ______________________
% Reliability: _________
General Data:
Patients Name: _____________________________
Age: ______ Sex: _______ Marital Status: ________
Address: _________________________________________________
Birthday: ________________ Birthplace: _______________________
Nationality: ______________ Religion: _________________________
Occupation: __________________________
Date of Admission: ______________________
Time of Admission: ______________________
No. of times admitted at OM: ______________
Chief Complaint: ________________________________________
History of Present Illness:
Onset: _______________________________
Duration: _____________________________
Frequency: ___________________________
Setting at which the Symptom Occurred: _______________________
_______________________________________________________
Manifestations: ___________________________________________
Location: ________________________________________
Precipitating Factors: _______________________________
Quality: _________________________________________
Radiation: _______________________________________
Severity: ________________________________________
Aggravating Factors: ______________________________________
Alleviating Factors: ________________________________________
Previous Treatment for the Problem: __________________________
Associated Signs and Symptoms: _____________________________
________________________________________________________
Pertinent Positives and Negatives: ____________________________
________________________________________________________
Additional Notes: __________________________________________
________________________________________________________
________________________________________________________

Past Medical History:

Current Medications:
Generic
Brand

Dosage

Frequency

Purpose

Immunizations:
BCG DPT Polio Hepa B
Others: ________________________________________
Allergies:
Food: ___________________________________
Medications: ______________________________
Pollen/Animals/Others: ______________________
Childhood Illness:
rheumatic fever
polio
chicken pox
measles
mumps
others: ______________________________
Adult Illness:
Illness
Age
Date of Diagnosis
Hypertension
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Others
Surgical Procedures:
Date: _______________________________
Type of Operation: _____________________
Purpose: _____________________________
Previous Hospitalizations:
Date
Cause
Hospital

Screening Tests:
Test
Tuberculin test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
Xray/CT Scan/MRI
Others

Date

Treatment

Result

Menstrual and Obstetric History:

LMP: ____________ PMP: _______________
Age of menarche: ____________ Period: regular/irregular
Character of flow: ____________
Duration of period (range): ____________
No. of pads used per day: ____________
PMS: ___________________________________________________
Age of Menopause: _______
Age of 1st coitus: ________ No. of sexual partners: __________
History of post-coital bleeding, pelvic infection, dyspareunia?
Birth control methods used:
Artificial
Natural
condom
rhythm method
pills
withdrawal
spermicidal
abstinence
Others: ____________________________________
Length of time used: _________
Complications: ______________________________

Gravidity: ______ Parity: _______

OB Index: ________ Term
________ Preterm
________ Abortions/Miscarriages
________ Living Children
Date of Birth
Sex
Manner of Delivery
______________________
____________________
______________________
____________________
______________________
____________________
OB Hx: G _ P_ (T-P-A-L)
G1: When _________, NSD or CS d/t _________, delivered by
_________, where _________, M/F, weight _________, fetomaternal
complications _____________________, present status __________.
Family History:
Family
Member
Father
Mother
Others

Age

Health/
Diseases

Medical Problems for any blood-relative

Relationship to Px
Cancer
Hypertension
Diabetes
Tuberculosis
Heart Disease
Stoke
Kidney Disease
Arthritis
Blood Disorder
Asthma
Epilepsy
Mental Disorder

Age & Date

of Dx

Cause of
death

Age & Date of Dx

Personal and Social History:

No. of years married: ______
Health Status of Spouse: ______________
No. of Children: _______
Health Status of Children: ___________________________________
Highest Educational Attainment: ______________________________
Occupational History: _______________________________________
________________________________________________________
________________________________________________________
Occupational Hazards: _____________________________________
Smoking Habits:
non-smoker
smoker
ex-smoker
No. of sticks/packs per day: _________
Year started: ______
Year quitted: ______
Alcohol Consumption
never
occasionally
daily
weekly
Alcohol type: ___________________
Amount Consumed: ______________
Nutrition:
No. of meals per day: ________
Food preferences: ___________________
Coffee/tea/soda intake: _______________
Nutrient Supplement:: ________________
OTC: _______________________
Prohibited Drugs: _____________
Substance Abuse: _____________
Exercise: ___________________________________
Regularity of Sleep: ___________________________
Habits/hobbies: ______________________________
Sources of Stress: ___________________________
Coping Strategies: ___________________________
Living Conditions:
No. of years in current residence: _______

Previous place of residence: ____________

___________________________________
Type of residence: ___________________
No. of rooms: _______________________
No. of occupants: ____________________
Relationship to occupants: __________________________
________________________________________________
Source of Drinking Water: ___________________________
Garbage Disposal: _________________________________
Fecal Disposal: ___________________________________
Pet/s: __________________________________________
Personally gives bath to pets? Y/N
General State of neighborhood: _____________________
Review of Systems:
Constitutional:
Fever
Weight gain/loss
Chills
Fatigue
Skin:
Rashes
Itching
Lumps
Dryness
Color Change
Changes in Nails
Hair:
Baldness
Excess Hair
Head:
Headache
Dizziness
Lightheadedness
Trauma
Syncope
Tenderness
Eyes:
Pain
Redness
Double Vision
Blurred Vision
Use of Glass/Lenses
Photalgia
Lacrimation
Ears:
Hearing Problem
Earache
Discharge (color/consistency) ____________
Tinnitus
Vertigo
Nose and Sinuses:
Epistaxis
Nasal stuffiness
Discharge (color/consistency): ____________
Itching
Mouth and Throat:
Use of dentures
Mouth sores
Bleeding Gums
Toothache
Sore throat
Hoarseness
Dysphagia
Neck:
Pain
Stiffness
Lump
Breast:
Pain
Discharge
Lumps
Periodic Exam
Respiratory:
Cough
Sputum (color/quantity) ________
Hemoptysis
Dysnea
Wheezing
Cardiovascular:
Chest Pain
Palpitations
Orthopnea
Edema
Cyanosis
Paroxysmal Nocturnal Dyspnea
Easy Fatigability
Gastrointestinal:
Loss of appetite
Nausea
Vomiting
Hematemesis
Abdominal pain
Diarrhea
Hematochezia
Excessive belching/passing of gas
Renal:
Dysuria
Polyuria
Nocturia
Gross Hematuria
Incontinence
Urinary Retention
Urinary Urgency
Tea-Colored Urine
In Males:
Reduced caliber of force of stream

 Hesitancy
Dribbling
Genitalia:
Pain
Swelling
Discharge (characteristics): ________________
Ulcers
Itching
Peripheral vascular:
Leg cramps
Varicose veins
Muskuloskeletal:
Muscle weakness
Stiffness
Backache
Joint swelling
Muscle pain
Join Pain
Neurologic:
Paralysis
Numbness
Tremors
Seizures
Memory Loss
Hematologic:
Easy bruising
Bleeding
Pallor
Endocrine
Polydypsia
Polyphagia
Heat/cold intolerance
Excessive sweating
Psychiatric:
Nervousness
Depression
Anxiety
Hallucinations
PHYSICAL EXAMINATION
General Survey:
Mood: ______________
Distress/ Unusual Position: _____________
Cooperative/ Non-cooperative
Irritable/agitated/pleasant
Coherent: _________
Oriented to time and space: _______
Personal Hygiene: _______________
Level of Consciousness: _______________
Height: ____________
Weight: ____________
BMI: ______________
Vital Signs:
Temperature: ________
Respiration: _________
Pulse: _____________
Blood Pressure: _______

Oral Axillary Rectal

Normal Labored
Regular R. Irreg. Irr. irreg.
Lying Sitting Standing

Head:
Trauma: ________________________________
Size: ______________
Shape: _____________
Tenderness: __________________________________
Condition of hair and scalp: _______________________________
Symmetry: ___________________________
Masses: _____________________________
Eyes:
Visual acuity:
Far: (R) ________ (L) ________
Near: (R) ________ (L) ________
Visual Fields (H test): ___________________
Accommodation: _______________________
Test of confrontation: ___________________
Conjunctiva:
Color: ____________________________
Discharge: ________________________
Sclerae:
Color: ____________________________
Discharge: ________________________
Cornea:
Clarity: ___________________________
Corneal Arcus: _____________________
Lids: ______________ Iris: ________________
Position of eyes in orbits: ______________________________
Pupil:
Size: (R) __________ (L) ___________

Shape: ____________ Symmetry: ______________

Accommodation: _______________
Light reflex test (PERLA): ________________
EOM: ________________________
Visual Field: ____________________________
Direct Reaction: ____________ Consensual Reaction: ____________
Fundoscopic
Red orange reflex: ______________
Disc: ________________________
Macula: _____________________
Blood vessels: _________________
Ears:
Symmetry: _______________
Swelling: ______________________________
Redness: ______________________________
Discharge: ______________________________
Tenderness: _____________________________
Hearing Impairments: _______________________
Presence of Hearing Aid: _____________________
Weber Test: ______________________________
Rinne Test: (R) AC __________ BC ___________
(L) AC __________ BC ___________
Nose:
Symmetry: ___________________________
Frontal, maxillary sinus tenderness: ____________________
Obstruction: __________________________
Congestion: __________________________
Lesions: _____________________________
Exudates: ____________________________
Inflammation: _________________________
Throat:
Lips: _____________________
Teeth/dentures: _______________________
Gums: _______________________________
Tongue: _____________________________
Pharynx:
Lesions: ______________ Erythema: _____________
Exudates: _____________ Tonsillar Size: _________
Neck:
Symmetry: _________________________
Limitation of ROM: __________________
Tenderness: _________________________
JVD: ______________________________
Lymph nodes: ________________________
Size: _____________
Mobility: ___________
Tenderness: _____________
Borders: ________________
Consistency: _____________
Thyroid cartilage: _____________ Cricoid cartilage: ______________
Thyroid gland: ________________
Chest and Lungs
Inspection
Comfort and Breathing Pattern: _____________________
Shape of the Chest: ______________________________
Chest Movement: ________________________________
Use of Accessory Muscles of Breathing: ______________
Deformities of Asymmetry: _________________________
A/N Retraction of Interspaces on Inspiration: ___________
Impairment of Respiratory Movement: ________________
Color of Patient (Lips & Nail Bed): ___________________
Palpation
Tender Areas: ___________________________________
Respiratory Expansion (10th rib): Symmetry Yes No
Tactile Fremitus: Symmetry
Increased
Decreased Absent
Percussion: ____________________________________
Auscultation
Breath Sounds: _________________________________
Bronchophony Whispered Petoriloquy
Egophony

Heart:
Inspection
Precordial bulge or heave: __________________
PMI: __________________________
Palpation
PMI: __________________________
Thrill: _____
Location: _________________
Timing in Cardiac Cycle (S/D): ______________
Mode of Extension/Transmission: ____________
Friction Rub: ___________________
Percussion: Cardiac Borders
Right (cm)
ICS/MSL
Left (cm)
5th
4th
3rd
2nd
Auscultation
S1 (M-loud, T-split): ___________________
S2 (A,P-loud, P-split I): ___________________
S3: _________________________
Murmurs/Accessory Heart Sounds:
Location: __________________ Timing: _______________
Quality: ___________________ Pitch: ________________
Intensity: __________________ Radiation: _____________
Breast:
Symmetry: _____________
Dimpling/Skin Retraction: _____________________
Swelling: ____________________
Discoloration (Skin changes): _________________
Orange Peel Effect: _________________
Position and Characteristic of Nipple: _________________
Gynecomastia (Male): _________________
Mass:
Location: _____________________________
Size: ___________ Consistency: _________________
Tenderness: ______________ Mobility: _____________
Borders: _________________
Abdomen:
Inspection
Irregular Contours: ____________ Scars
Discoloration: ________________
Bulges: _____________________
Shape: _____________________
Striae: ______________________
Distance of umbilicus from xiphoid process: __________
Abdominal Girth: __________________
Auscultation
Bowel Sounds: Frequency: ___________ Character: ____________
Bruit: ___________________
Venous Hum: ______________
Friction Rub: _______________
Percussion
Liver Span: _______________ Normal: 6-12 cm in (R)MCL
Splenic Dullness: ______________
Other Areas of Dullness: _______________
Special Tests
Rebound Tenderness: Rovsings, Blumberg
Costovertebral Tenderness
Shifting Dullness
Psoas Sign
Murphys Sign
Male Genitalia:
Penile Lesions: _______________
Scrotal Swelling: _______________________
Testicles
Size: ________ Tenderness: ___________
Masses: ______________
Varicocoele: _________________
Hernia: ________________
Transillumination: ________________

Extremities:
Amputation
Deformities
Tenderness
Warmth

Visible joint swelling

Limitation of ROM
Redness
Edema

Capillary refill: ______________

Peripheral pulses: ___________
NEUROLOGICAL EXAMINATION
Mental Status Examination
A. Awareness
Orientation
Name: Season Date Day Month Year
Name: Hospital Floor Town State Country
Level of consciousness:
B. Speech (Normal, dysphasia, dysarthria, dysphonia)
C. Language
Name: Pencil Watch
Repeat: No ifs ands or buts
D. General Knowledge
Knowledge of current events, vocabulary
(Historical events, 5 last presidents, 5 largest cities)
E. Memory
Immediate, recent, remote
F. Registration (Retention and recall)
Identify: Object 1 Object 2 Object 3
Attention and Calculation
(100-7): 93 86 79 72 65
Recall
Recall: Object 1 Object 2 Object 3
G. Reasoning
Judgment, Insight, abstraction (interpretation of proverbs)
H. Object recognition
Agnosia (Visual, tactile, auditory, autotopagnosia, anosognosia)
Praxis (Ideomotor, Ideational)
Perception (Delusion, Hallucination, illusion, astereognosis,
agraphestesia)
I. Follows Command
Take this paper. Fold it in half. Place it on the table.
Obey written command.
Write a sentence.
Copy a design.
Total: _____
Cranial Nerve Examination
CN I
Identify odorant
CN II
Visual acuity: ________ Visual field: _________
Fundoscopy: ____________________________________________
CN III, IV, VI
Size and Shape of Pupil: __________________
Light Reaction
Accommodation
EOM:
Paresis
Nystagmus
Saccades
Oculomotor Ataxia
Diplopia
Other _____________
CN V
Ophthalmic
Maxillary
Mandibular
Corneal Reflex
Jaw Clench
CN VII
Eyebrow Elevation
Forehead Wrinkling
Eye Closure
Smiling
Cheek Puffing
CN VIII
Hear finger rub or whispered voice
Rinne: ____________
Weber: ____________
CN IX, X
Palate and Uvula: _____________
Gag Reflex

CN XI
Shoulder Shrug (against resistance)
Head Rotation (against resistance)
CN XII (Tongue)
Atrophy
Fasciculation
Position with protrusion: _________
Strength: __________

Ankle
Superficial
Abdominal
Cremasteric
Reflexes in Infants
Grasp
Suck
Moro
Rooting
Tonic neck
Babinski

Motor Examination
Involuntary Movements
Symmetry
Atrophy
Gait
Paresis
Paralysis
Spasticity
Rigidity
Flaccidity
Clonus
Carpopedal Spasm
Tics
Tremors
Athetosis
Others

Sensory
Pin prick
Touch
Two point discrimination
Sense of Position
Vibratory Sense
Superficial sensation
Deep Sensation

Tone
Description: ____________________________
Flaccidity
Spasticity
Muscle Strength
(R)
Shoulder Flexion
Extension
Abduction
Adduction
IR/ER
Flexion at the elbow
Extension at the elbow
Extension at the wrist
Squeeze 2 of your fingers as hard as possible
Finger abduction
Opposition of the thumb
Flexion at the hips
Adduction at the hips
Abduction at the hips
Extension at the hips
IR/ER
Extension at the knee
Flexion at the knee
Dorsiflexion at the ankle
Plantar flexion
Coordination and Gait
Rapid Alternating Movements
Point to Point Movements
Romberg
Gait
Walk across the room, turn and come back
Walk heel-to-toe in a straight line
Walk on heels in a straight line
Walk on toes in a straight line
Hop in place on each foot
Shallow knee bend
Rise from a sitting position
Reflexes
Deep Tendon
Biceps
Triceps
Brachioradialis
Knee

(L)