HISTORY Convulsions:_______
Date of Interview: ______________________________
Time of History: _______________________________
Informant: ____________________________________
Relationship to the Patient: ______________________
% Reliability: _________
General Data:
Patients Name: _____________________________
Age: ______
Birthdate: _____________
Birthplace:_______________________
Sex: _______
Address:_________________________________________
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:
__________________________________________
_______________________________________________
_______________________________________________
PERSONAL HISTORY
Gestational History: (<2y/o)
Age of mother during pregnancy: _____________________
Mothers OB index:________
Mothers health, nutrition, drug intake, exposure:_________
Duration of gestation:__________
Birth: (<2y/o)
Term/Premature/Post-mature: _______
Manner of delivery: __________
Person who attended delivery:______
Birth weight:___________
Neonatal History: (<2y/o)
APGAR score: _______
Spontaneous respi? ______
Cyanosis/Pallor: _____
Cry: _______
Jaundice (age of onset):________
Hemorrhage:_______
Respi/feeding difficulties: ______________
Congenital abnormalities: ____________
Birth injury: ________________
Feeding History
Infancy (<2y/o):
Type of feeding:
Breastfeeding:____________________________
Formula: ________________________________
Complementary foods
Age introduced: ___
Foods initially & subsequently given: __________
Frequency of feeding per day: _______________
Usual food intake
Breakfast:_______________
Lunch: _________________
Dinner: ________________
Snacks: _______________
Compute actual caloric intake: ____ & Compare w/ RENI __
Food intolerance: _______
Multivitamin & Iron supplements: _________________
Caregiver: _________
Childhood & Adolescents (2-20 y/o):
Appetite: _______________
Usual food intake and amount per day:
Breakfast: ____________________________
Lunch: _______________________________
Dinner: _______________________________
Snacks: _______________________________
Compute actual caloric intake: ____ & Compare w/ RENI __
Food likes or dislikes: ______________
Feeding difficulties: _________________
Multivitamin & Iron supplements: _________________
Development/Behavioral History
Young Children (1-5 y/o):
Use Devt. Checklist in book (p.110): ___________________
Dental eruption: ______________
Urinary continence (day/night): ______________
Toilet training: started______, completed ____________
Head banging: ______________
Phobias: ____________ Night terrors:________________
Middle Childhood (6-11 y/o):
School performance: _____________
Sexual development (Tanners): _______________
Adolescence (10-20 y/o):
HEADSSS: Home ________, Education ________,
Eating habits ________, Activities _________,
Drugs __________, Sexual _________,
Suicidal ________
Sexual Devt (Tanners): ______________
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 Immunization History & Tuberculin Test
condom rhythm method BCG: ________________________________
pills withdrawal DPT: __________________________________
spermicidal abstinence Polio: _________________________________
Others:_________________________________ Hepa B: ________________________________
Length of time used: _________ Measles: _______________________________
Complications:____________________________ Others: ________________________________________
Adverse effects: ______________________________
Gravidity: ______ Parity: _______ Tuberculin Test: ______________________________
OB Index: ____Term, ___ Preterm,
_____Abortions/Miscarriages, ____ Living Children Family History:
G1: When _________, NSD or CS d/t _________, delivered by Family Age Occupation Health/ Age & Cause
_________, where _________, M/F, weight _________, Member Diseases Date of of
fetomaternal complications _____________________, present Dx Death
status __________. Father
Mother
Past Illnesses Siblings
Allergies:
Food: ___________________________________
Medications: _____________________________
Pollen/Animals/Others:______________________ Medical Problems for any blood-relative
Childhood Illness:
rheumatic fever polio chicken pox Rel. to Px Age & Date of Course of
measles mumps pertussis Dx Illness
others: ______________________________ Tuberculosis
Describe clinical course: Diabetes
_______________________________________________ Syphilis
Adult Illness: Cancer
Illness Age Date of Epilepsy
Diagnosis Rheumatic
Asthma fever
Eczema Allergy
Hypertension Asthma
Stroke Hypertension
Renal Heart Disease
TB Stroke
DM Kidney
Cardiac Disease
GI Arthritis
STD Blood
Others Disorder
Mental
Surgical Procedures: Disorder
Date: _______________________________ Others:
Type of Operation: _____________________
Purpose: _____________________________ Socioeconomic History
Previous Hospitalizations: Living Conditions:
Date Cause Hospital Treatment No. of years in current residence: _______
Previous place of residence: ____________
Type of residence: ___________________
No. of rooms: _______________________
No. of occupants: ____________________
Screening Tests: Relationship to occupants: _________________
Test Date Result Economic Circumstances:
Tuberculin test Members of family who work: ____________
Pap Smear Source of funds: _______________________
Mammogram
Occult blood in
stool Environmental History
Exposure to cigarette smoke: ____________________
Cholesterol test
Other pollutants: ________________________
Urinalysis
Source of Drinking Water: ________________
Xray/CT Scan/MRI Source of Washing water: ____________________
Others Garbage Disposal: ______________________
Fecal Disposal: ____________________
Injuries: _________________________________________ Pet/s: _______________Personally gives bath to pets? Y/N
General State of neighborhood: ______________
Others:
No. of years married: ______ Lumps Periodic BSE
Health Status of Spouse: ______________ Respiratory:
No. of Children: _______ Cough Sputum (color/quantity)
Health Status of Children: ________________________ ________
Hemoptysis Dyspnea Wheezing
Highest Educational Attainment: ____________________ Cardiovascular:
Occupational History: _____________________________ Chest Pain Palpitations
Occupational Hazards: ____________________________ Orthopnea Edema
Smoking Habits: Cyanosis Paroxysmal Nocturnal Dyspnea
non-smoker smoker ex- Easy Fatigability
smoker Gastrointestinal:
No. of sticks/packs per day: _________ Bowel characteristics: ______________________________
Year started: ______ Year quitted: ______ Loss of appetite Nausea
Alcohol Consumption Vomiting Hematemesis
never occasionally Abdominal pain Diarrhea
daily weekly Hematochezia Constipation
Alcohol type: ___________________ Excessive belching/passing of gas
Amount Consumed: ______________ Pica Passage of worms
OTC: _______________________ Encopresis Food intolerance
Prohibited Drugs: _____________ Renal:
Substance Abuse: _____________ Urine characteristics:_______________________________
Exercise: ___________________________________ Burning sensation Dysuria
Regularity of Sleep: ___________________________ Enuresis Polyuria
Habits/hobbies: ______________________________ Nocturia Gross Hematuria
Sources of Stress: ___________________________ Incontinence Urinary Retention
Coping Strategies: ___________________________ Urinary Urgency Tea-Colored Urine
In Males: Reduced caliber of force of stream
REVIEW OF SYSTEMS Hesitancy
General: Dribbling
Fever Weight gain/loss Genitalia:
Chills Fatigue Pain Swelling
Activity level: ____________________ Discharge (characteristics): ________________
Appetite: _____ Ulcers Itching
Delay in growth: _______ Peripheral vascular:
Leg cramps Varicose veins
Skin: Muskuloskeletal:
Rashes Itching Muscle weakness Stiffness
Lumps Dryness Backache Joint swelling
Color Change Changes in Nails Muscle pain Join Pain
Hair: Limitation of motion Limping
Baldness Excess Hair Neurologic:
Head: Paralysis Numbness
Headache Dizziness Tremors Convulsions
Lightheadedness Trauma Memory Loss Sleeping problems
Syncope Tenderness Mental deterioration
Eyes: Hematologic:
Pain Redness Easy bruising Bleeding
Double Vision Blurred Vision Pallor
Use of Glass/Lenses Photalgia Endocrine
Lacrimation Polydipsia Polyphagia
Ears: Heat/cold intolerance Excessive sweating
Hearing Problem Earache Psychiatric:
Discharge (color/consistency) ____________ Nervousness Depression
Tinnitus Vertigo Anxiety Hallucinations
Nose and Sinuses: Eating problems Mood changes
Epistaxis Nasal stuffiness Personality/Behavior changes
Discharge (color/consistency): ____________ School failures Temper outbursts
Itching
Mouth and Throat: PHYSICAL EXAMINATION
Use of dentures Mouth sores General Survey:
Bleeding Gums Toothache Level of activity: ________________
Sore throat Hoarseness Distress/ Unusual Position: ___________
Dysphagia Salivation Ambulatory/Bedridden
Nutritional state: ___________ Ill-looking? ________
Neck:
Pain Stiffness Mood: ______________
Lump Cooperative/ Non-cooperative
Breast: Irritable/agitated/pleasant
Pain Discharge Coherent: _________
Oriented to time and space: _______
Personal Hygiene: _______________
Level of Consciousness: ______________
Vital Signs:
Temp: ________ Oral Axillary Rectal
RR: _________ Normal Labored
PR: ___, Volume: _______ Regular R. Irreg. Irr. irreg.
BP (>3y/o) R arm: ______ Lying Sitting Standing
BP (>3y/o) L arm: _______, Ankle: _________
Anthropometric Data:
Weight: ____________
Length (<2y/o), Height (>2y/o): ____________
BMI: ______________
Head circumference (<3y/o): _______________
Chest circumference: ______________
Arm span: _____________
Upper segment: ___________, Lower segment: _________
Skin:
Color: _____________
Tissue turgor: _____________
Loss of subcutaneous tissue: _____________
Rash/eruptions: ____________________
Hemorrhages: ______________
Edema: _____________
Jaundice: ___________________
Head:
Hair: Quantity________
Color ____________
Texture ______________
Lice/nits: ______________
Strength ____________
Size: _________ Shape: _____________
Trauma: ______ Tenderness:____________ Lesions: _____
Fontanels: ______________
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 (20 by 2y/o): _______________________
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: _____________________
Size and Shape of Chest (CC<HC in 9-12mos; CC>HC by
1y/o; Transverse >AP diameter in <2y/o): ______________
Chest Movement: ________________________________
Use of Accessory Muscles of Breathing: ______________
Deformities or 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
 Hernia: ________________
Heart: Transillumination: ________________
Inspection
Dynamic/Adynamic Extremities:
Precordial bulge or heave: __________________ Amputation Visible joint swelling
PMI (4th LICS MCL up to 7y/o; then 5th LICS MCL): _______ Deformities Limitation of ROM
Palpation Tenderness Redness
PMI: __________________________ Warmth Edema
Thrill: _____
Location: _________________ Capillary refill: ______________
Timing in Cardiac Cycle (S/D): ______________ Peripheral pulses: ___________
Mode of Extension/Transmission: ____________
Friction Rub: ___________________ Mental Status Examination
Auscultation A. Awareness
S1 (M-loud, T-split): ___________________ Orientation
S2 (A,P-loud, P-split I): ___________________ Name: Season Date Day Month Year
S3: _________________________ Name: Hospital Floor Town State Country
Murmurs/Accessory Heart Sounds: Level of consciousness:
Location: ___________ Timing: ____________ B. Speech (Normal, dysphasia, dysarthria, dysphonia)
Quality: ____________ Pitch: _____________ C. Language
Intensity: ___________ Radiation: ___________ Name: Pencil Watch
Repeat: No ifs ands or buts
Breast: D. General Knowledge
Symmetry: _____________ Knowledge of current events, vocabulary
Dimpling/Skin Retraction: _____________________ (Historical events, 5 last presidents, 5 largest cities)
Swelling: ____________________ E. Memory
Discoloration (Skin changes): _________________ Immediate, recent, remote
Orange Peel Effect: _________________ F. Registration (Retention and recall)
Position and Characteristic of Nipple: _________________ Identify: Object 1 Object 2 Object 3
Gynecomastia (Male): _________________ Attention and Calculation
Mass: (100-7): 93 86 79 72 65
Location: _____________________ Recall
Size: ___________Consistency: ____________ Recall: Object 1 Object 2 Object 3
Tenderness: ______________ Mobility: _______ G. Reasoning
Borders: _________________ Judgment, Insight, abstraction (interpretation of proverbs)
H. Object recognition
Abdomen: Agnosia (Visual, tactile, auditory, autotopagnosia,
Inspection anosognosia)
Irregular Contours: ____________ Scars Praxis (Ideomotor, Ideational)
Discoloration: ________________ Perception (Delusion, Hallucination, illusion, astereognosis,
Bulges: _____________________ agraphestesia)
Shape: _____________________ I. Follows Command
Striae: ______________________ Take this paper. Fold it in half. Place it on the
Distance of umbilicus from xiphoid process: __________ table.
Abdominal Girth: __________________ Obey written command.
Auscultation Write a sentence.
Bowel Sounds: Frequency: ___________ Character: Copy a design.
____________ Total: _____
Bruit: ___________________
Venous Hum: ______________ Cranial Nerve Examination
Friction Rub: _______________ CN I
Percussion Identify odorant
Liver Span: _______________ Normal: 6-12 cm in (R)MCL CN II
Splenic Dullness: ______________ Visual acuity: ________ Visual field: _________
Other Areas of Dullness: _______________ Fundoscopy:
Special Tests ____________________________________________
Rebound Tenderness: Rovsings, Blumberg CN III, IV, VI
Costovertebral Tenderness Size and Shape of Pupil: __________________
Shifting Dullness Light Reaction Accommodation
Psoas Sign EOM:
Murphys Sign Paresis Nystagmus
Saccades Oculomotor Ataxia
Male Genitalia: Diplopia Other _____________
CN V
Penile Lesions: _______________
Scrotal Swelling: _______________________ Ophthalmic Maxillary
Testicles Mandibular Corneal Reflex
Size: ________ Tenderness: ___________ Jaw Clench
CN VII
Masses: ______________
Varicocoele: _________________ Eyebrow Elevation Forehead Wrinkling
 Eye Closure Smiling Gait
Cheek Puffing Walk across the room, turn and come back
CN VIII Walk heel-to-toe in a straight line
Hear finger rub or whispered voice Walk on heels in a straight line
Rinne: ____________ Weber: ____________ Walk on toes in a straight line
CN IX, X Hop in place on each foot
Palate and Uvula: _____________ Shallow knee bend
Gag Reflex Rise from a sitting position
CN XI
Shoulder Shrug (against resistance) Reflexes
Head Rotation (against resistance) Deep Tendon
CN XII (Tongue) Biceps
Atrophy Fasciculation Triceps
Position with protrusion: _________ Brachioradialis
Strength: __________ Knee
Ankle
Motor Examination Superficial
Involuntary Movements Abdominal
Symmetry Cremasteric
Atrophy Reflexes in Infants
Gait Grasp
Paresis Suck
Paralysis Moro
Spasticity Rooting
Rigidity Tonic neck
Flaccidity Babinski
Clonus
Carpopedal Spasm
Tics Sensory
Tremors Pin prick
Athetosis Touch
Others Two point discrimination
Sense of Position
Tone Vibratory Sense
Description: ____________________________ Superficial sensation
Flaccidity Deep Sensation
Spasticity

Muscle Strength

(R) (L)
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