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 QCGH:
_
CHIEF COMPLAINT
________________________________
HISTORY OF PRESENT ILLNESS
Onset: _________
________________________
Duration: ________
Frequency: _______
Location: ________________
Precipitating Factors: ________________________________
Quality: _________________
Radiation: ________________________
Severity: __
Aggravating Factors: ______
Alleviating Factors:_______________________________________
Previous Treatment for the Problem: _______________________
Associated Signs and Symptoms:
________________________________________
________________________
Additional Notes:
________________
_________
________
_________
PAST MEDICAL HISTORY
Current Medications:
Generic
Brand
Dosage

Frequency

Purpose

Surgical Procedures:
Date: _____________________________________________
Type of Operation: __________________________________
Purpose: __________________________________________
Previous Hospitalizations:
Date
Cause
Hospital
Treatment

Screening Tests:
Test
Tuberculin Test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
X-ray/CT Scan/MRI
Coagulation Test

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

Immunizations:
BCG DPT Polio Hepa B Measles
Others: ____________________________________________
Allergies:
Food: ______________________________________
Medications: ________________________________
Pollen/Animals/Others: ______________________
Childhood Illness:
Rheumatic Fever
Polio
Chicken Pox
Measles
Mumps
Others: ____________________________________
Adult Illness:
Illness
Age
Date of Diagnosis
HPN
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Others

Date

Sex

Manner of Delivery

OB History: 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
Age
Member
Father
Mother
Others

Health/Diseases

Age and
Date of
Dx

Cause of
Death

Medical Problems for any blood-relative

Disease
Relationship to Px

Head

Cancer
HPN
Diabetes
TB
Heart Disease
Stroke
Kidney
Arthritis
Blood Disorder
Asthma
Epilepsy
Mental Disorder
Galbladder dse

Tenderness
Trauma

Eyes
Pain
Double vision
Use of glass/lenses
Lacrimation

Redness
Blurred vision
Photalgia

Ears

PERSONAL AND SOCIAL HISTORY

No. of years married: ______
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
ocassionally
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
Skin
Rashes
Lumps
Color change
Hair
Baldness

Headache
Dizziness
Lightheadedness
Syncope

Age and Date of

Dx

Fatigue
Itching
Dryness
Changes in nails
Excess hair

Hearing problem
Earache
Discharge (color/consistency): ____________
Itching
Mouth and Throat
Use of dentures Mouth sores
Bleeding gums Sore throat
Hoarseness
Dysphagia
Toothache
Neck
Pain
Stiffness
Lump
Breast
Pain
Discharge
Lumps
.Periodic exam
Respiratory
Cough
Sputum color/quantity): ____
Hemoptysis
Dyspnea
Wheezing
Cardiovascular
Chest pain
Palpitations
Orthopnea
Edema
Cyanosis
Paroxysnal Nocturnal Dyspnea
Easy Fatigability
Gastrointestinal
Loss of appetite
Nausea
Vomiting
Hematemesis
Abdominal pain
Dysphagia
Hematochezia
Diarrhea
Hemorrhoids
Constipation
Stool: ________________
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
Musculoskeletal
Muscle weakness
Stiffness
Backache
Joint swelling
Muscle pain
Joint pain
Neurologic
Paralysis
Numbness
Tremors
Seizures
Memory Loss
Hematologic
Easy bruising
Bleeding
Pallor
Endocrine
Polydipsia
Polyphagia
Heat/cold intolerance
Excessive sweating
Psychiatric
Nervousness
Depression
Anxiety
Hallucinations

PHYSICAL EXAMINATION
General Survey
Mood: ____________________________________________
Distress/Unusual Position: ____________________________
Cooperative / Non-cooperative: ________________________
Irritated / 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. Irregular
Irr. irregular
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: ______________________________________________
Position of eyes in orbits: _____________________________
Pupil
Size: (R) ____________
(L) _____________
Shape: _____________
Symmetry: ____________
Accommodation: ____________________________
Light reflex test (PERLA): ______________________
EOM: ______________________________________
Visual Field: _________________________________
Direct Reaction: ________ Consensual Reaction: _________
Fundoscopy
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: ________________________________________
JVP: ______________________________________________
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 or Asymmetry
A/N Retraction of Interspaces on Inspiration
Retraction of the interspaces when breathing
Color of Patient (Lips and Nail Bed): ______________________
Palpation
Tender Areas: ________________________________________
th
Respiratory Expansion (10 rib): __________________________
Tactile Fremitus:
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
th
5
th
4
rd
3
nd
2

Left (cm)

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 Characteristics 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
Visible joint swelling
Deformities Limitation of ROM
Tenderness Redness
Warmth
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:___________________________________________

 Babinski

Motor Examination
Involuntary Movements
Symmetry
Atrophy
Gait
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 band
Rise from a sitting position
Reflexes
Deep Tendon
Biceps
Triceps
Brachioradialis
Knee
Ankle
Superficial
Abdominal
Cremasteric
Reflexes in Infants
Grasp
Suck
Moro
Rooting
Tonic neck

(L)