CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

HISTORY

I. General Data
Name: _______________________________________________
Age: _________________________________________________
Gender: ______________________________________________
Address: ______________________________________________
Date of Birth: ___________________________________________
Place of Birth: __________________________________________
Birth Order: ____________________________________________
Civil Status: ____________________________________________
Nationality: _____________________________________________
Religion: _______________________________________________
Handedness: ___________________________________________
Highest educational attainment: _____________________________
Rank: _________________________________________________
Years of Service: ________________________________________
Military Base Assignment: _________________________________
Reliability: ___________________________________________

Admissions Date of Admission Place of Admission/ Diagnosis

Hospital
1st
2nd
Latest

II. Chief Complaint

According to the patient, “__________________________________________________________”
“__________________________________________________________”
According to the patient’s chart: “____________________________________________________”

III. Premorbid Personality

(Note: how the patient perceives himself before his illness, include his description about himself, how he
deals with his problems, hobbies etc.)

IV. History of Present Illness

(Note: thoughts, feelings, action, results & Onset, Precipitating factors, Quality, Relieving, Severity, Timing,
Pertinent negatives)
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

V. Past Medical History:

Medical
Year Diagnosis Treatment Compliance/ Response
Hospital

Surgical
Year Diagnosis Treatment Compliance/ Response
Hospital

Psychiatric
Year Diagnosis Treatment Compliance/ Response
Hospital

Immunization, Blood transfusion, Allergies:

VI. Family Medical History_______________________________________________________________

Medical
Family Member Diagnosis Deceased/ Alive

Psychiatric
Family Member Diagnosis

Family Profile
Family Member Age/Sex/Civil Educational Occupation Description Health Status
Status Attainment
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

Genogram

VII. Personal and Social History

Lifestyle
Diet: ____________________________
Eating habits: _____________________
Hobbies: ________________________
Activities: ________________________

Sexual History
Gender preference: ______________________
Year/ age of first coitus: ___________________
1st relationship:_______________ year/ age: ___ reason for breaking up: _____________________
2nd relationship: ______________ year/age: ___ reason for BU: ____________________________

Fraternity or Gang:
Name: __________________________________________ Active: yes/no
Activities: ________________________________________ Hazing: ________________________
Reasons for joining: _______________________________________

Gambling:
Years: __________________________________
Year/ age started: _________________________
Frequency: ______________________________
Implication in life: _________________________

VIII. Substance Use History

1. Smoking
Years: _________________________________
Number of sticks per day: __________________
Year/ age started: ________________________
Who influenced him/her: ___________________
Stressor: ________________________________
Feeling: ________________________________

2. Alcohol (MUST BE DETAILED TO RULE OUT SUBSTANCE ABUSE)

Years: ___________________________________
Number of bottles per day (Better if volume): ___________________
Year/ age started: __________________________
Who influenced him/her: _____________________
Last intake of alcohol: ______________________________
Reasons for drinking: ___________________________
Stressor: _________________________________
Feelings: _________________________________
Symptoms: ( ) seizure ( ) loss of consciousness
Symptoms of Alcohol abuse and use (Look for the criteria for Alcohol abuse and use):
__________________________________________
Withdrawal symptoms: __________________________

3. Drugs
Specific drug: ______________________________
Year/ age started: ___________________________
Who influenced him/her: ______________________
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!
Stressor: __________________________________
Feelings: __________________________________
Symptoms: ________________________________
Symptoms of Substance abuse and use (Look for the criteria for Alcohol abuse and use):
__________________________________________
Withdrawal symptoms: __________________________

IX. Review of Systems (Ask more on psychiatric symptoms ex. Tremors, fatigue, anxiety
manifestations)

General: ( ) weight loss/gain ( ) increased/loss of appetite ( ) fever/chills

Skin: ( ) rashes ( ) bruises ( ) cuts
HEENT: Head: ( ) headache ( ) dizziness
Eyes: ( ) blurring of vision ( ) eye pain
Ears: ( ) tinnitus
Nose: ( ) epistaxis
Throat: ( ) dysphagia ( ) odynophagia
Respiratory: ( ) shortness of breath ( ) difficulty of breathing ( ) colds ( ) cough
Cardiovascular: ( ) palpitation ( ) chest pain
Gastrointestinal: ( ) abdominal pain ( ) constipation/diarrhea
Genitourinary: ( ) polyuria ( ) oliguria ( ) dysuria ( ) changes in urine character
Musculoskeletal: ( ) joint pain/ swelling ( ) muscle pain ( ) limitations in movement
Endocrine: ( ) polyuria ( ) polydipsia ( ) polyphagia ( ) heat/cold intolerance ( ) profuse sweating

ANAMNESIS

(Always ask for the feelings and dig deeper. Note: A good tool for diagnosing personality disorder
is a good anamnesis)

I. Prenatal and Perinatal

Name of mother: ______________________________________
Age of mother: _______________________________________
GP score: ___________________________________________
Planned/unplanned: ___________________________________
Prenatal check-up: ____________________________________doctor/midwife: ________
Vitamins, vaccines: ____________________________________
Exposure: infections, smoking, alcohol, drugs: ________________________________
Mode of delivery: __________________________ doctor/midwife: _______________
Place of birth including name of hospital: _____________________________________
Term/preterm: ________________________________________
Complications: _________________________________________________________
Birth defects: ___________________________________________________________
Additional notes:

II. Infancy and Early Childhood (Birth to 3 y/o)

Primary caregiver: __________________ if not mother reason: __________________________________
Breastfeeding: ____________________________________
Complementary feeding: ____________________________
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!
Appetite: _________________________________________
Allergies: _________________________________________
Picky eater?: ______________________________________
Temper tantrum: ____________________________________ ( ) hyperactivity ( ) head banging ( ) rocking
Sleep disturbance: __________________________________
Close family member: ________________________________
Additional notes:

III. Middle Childhood (3-11 y/o – elementary)

Age began school: ___________________
Place and name of school: __________________________________________
Accompanied by: __________________________________
Feelings regarding going to school: ______________________________________
Friends: ______________________________________________
Bullying: _____________________________________________
Play: _________________________________________________
Academic standing: __________________________________
Favorite subject: ____________________ why?: _____________________________________
Skipping school: __________________________________
Petty thievery: ___________________________________
Enuresis: _______________________________________
Fears: __________________________________________
Additional notes:

IV. Late Childhood (puberty- adolescence; HS to College)

High school
Place and name of school: ________________________________
Who paid the tuition: ____________________________________
Feelings: ______________________________________________
Academic standing: ______________________________________
Favorite subject: ____________ why?: ________________________________________________
Extracurricular activities: _______________________________________
Friends: ____________________________________________________
Vices: ( ) smoking ________________________________________________________________
( ) alcohol _________________________________________________________________
( ) drugs __________________________________________________________________
Crushes/ Relationship: ____________________________________________________________
Problems in school: _______________________________________________________________
Additional Notes:
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

College
Place and name of school: ____________________________________
Who paid the tuition: _________________________________________
Course: ___________________ why?: ________________________________________________
Feelings: __________________________________________________
Academic standing: __________________________________________
Favorite subject: __________ why?: __________________________________________________
Extracurricular activities: _______________________________________
Friends: ____________________________________________________
Vices: ( ) smoking ________________________________________________________________
( ) alcohol _________________________________________________________________
( ) drugs __________________________________________________________________
Crushes/ Relationship: ____________________________________________________________
Problems in school: _______________________________________________________________
Additional Notes:

V. Adulthood
i. Occupation
1st work_____________ place and name of agency: _____________________________________
Years: __________ Salary: _____________________________________
Reason for quitting: ___________________________________________
Feelings: ___________________________________________________
Additional notes:

2nd work_____________ place and name of agency: ____________________________________

Years: __________ Salary: _____________________________________
Reason for quitting: ___________________________________________
Feelings: ___________________________________________________
Additional notes:

ii. Marital and Relationship History

Current Relationship
Name of partner: _____________________________________________
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!
Description of partner: __________________________________________
How did they meet: ___________________________________________
Work of partner: _____________________________________________
Married/ not: ________________________________________________
Problems: __________________________________________________
How do they solve their problems: _________________________________

Children age gender caregiver Where he/she Status of

lives relationship
(close/not)

Additional notes:

Summary of past relationships

Age How long Parent’s Reason for Moved on/ Feelings
opinion breaking-up not
1st
2nd
3rd
4th
5th
Additional notes:

iii. Military History

How did he enter: ________________________________________________________________
Who influenced him to enter military: _________________________________________________
Inspiration: _____________________________________________________________________
Training: _______________________________________________________________________
Feelings: _______________________________________________________________________
Specific duties: __________________________________________________________________
Relationship with colleagues: _______________________________________________________
First encounter: ________________________ feelings: __________________________________
Succeeding encounters:

Promotions: _____________________________________________________________________

Additional notes:
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

iv. Educational History

Elementary:

High School:

College:

v. Religion
Religion: _____________________________
Do all family members have the same religion?: _________________________________________
Mass: __________________________________________________________________________
Does he consider himself as devout?: _________________________________________________
Reads Bible: ____________________________________________________________________
Additional notes:
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

vi. Social Activity

How does he spend his free time:__________________________________________________

vii. Current Living Situation

Address: _______________________________________________________________________
Description of house: _____________________________________________________________
Number of people in the house: ______________________________________________________

viii. Legal History

VI. Sexual History

Gender preference:__________________________________________
Circumcision:
Age: ____________
Who performed: _____________________ where: ___________________________________________
Masturbation
Age: __________________
Where: ______________________________________________________________________________
Who influenced: _______________________________________________________________________
Feelings: _____________________________________________________________________________

Name Age How did they meet Contraceptive use Feelings

VII. Fantasies and Dreams

Dreams
Self: _________________________________________________________________________________
Family: _______________________________________________________________________________
Partner: ______________________________________________________________________________
Children: _____________________________________________________________________________
Additional notes:
CLASS OF 2018: SULONG LABING WALO! WALANG PATATALO!

VIII. Values

(Guys maging tsismosa kayo paminsan minsan hahaha! This will help you establish a good differential
diagnosis! God bless and congrats in advance)
SULONG LABING WALO! WALANG PATATALO!