HEALTH HISTORY

I. Biographical Data:

Name of Patient:

Age:

Sex:

Contact Number:

Address:

Date of Birth:

Place of Birth:

Religious Affiliation:

Ethnic Group/Race:

Marital Status:

Occupation:

Educational Level:

Source of Health History:

Health Insurance:

Contact Person or Tel.No.:

II. Chief Complaint(s)/Reason(s) for Seeking Health Care:

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 III. History of Present Illness:

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 IV. Personal and Social History:

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V. Review of Systems (Subjective Data):

Respiratory System:

Cardiovascular System:
Digestive System:
 General Survey:

Signs of Distress:

Affective Expression:

Body Type:

Gait:

Posture:

Body Movements:

Hygiene/grooming, odor:

Speech:

Mental State - Level of Consciousness:

Vital Signs:

Temperature:

Pulse:

Respiration:

Blood Pressure:
Physical Assessment Findings:

Posterior and Anterior Chest:

INSPECTION

Posterior Chest Anterior Chest Remarks

Rate of Respiration

Rhythm of Respiration

Depth of Respiration

Effort/Use of Accessory
Muscles

Shape of Chest

Symmetry

PALPATION:

Posterior Chest Anterior Chest Remarks

Masses

Tenderness

Crepitus

Respiratory Excursion Findings:

Posterior Chest Anterior Chest Remarks

Symmetrical
Movements of the
Thumb

Overall Findings

Inches
Tactile Fremitus:

Posterior Chest Anterior Chest Remarks

Overall Findings

Degree of Vibrations

PERCUSSION:

Posterior Chest Anterior Chest Remarks

Overall Findings

Abnormalities

AUSCULTATION:

Posterior Chest Anterior Chest Remarks

Overall Findings

Abnormalities

Heart Sounds:

Abnormalities: S1 S2 Remarks
Rate

Rhythm

Abnormal Sounds
DIGESTIVE SYSTEM

INSPECTION: Findings Remarks (if abnormal)

Size
Shape
Symmetry
Color
Hair
Distribution
Lesions
Striae
Movements

UMBILICUS Findings Remarks (if abnormal)

Position
Contour
Color
Discharge
Bulges
Movements:
Respiration
Peristalsis
Pulsations

AUSCULTATE RLQ RUQ LUQ LLQ

Findings
Bowel sounds per
minute (RLQ)
Bruit
PERCUSSION RLQ RUQ LUQ LLQ
Findings

PERCUSSION OF LIVER

Distance of Marks in cm

PALPATION: RLQ RUQ LUQ LLQ

Characteristics

Tenderness

DEEP PALPATION

Tenderness
Rigidity
Masses
Enlarged Organs
PALPATION OF LIVER
Consistency

Tenderness