Xavier University – Ateneo de Cagayan

Jose P Rizal School of Medicine

PATIENT HISTORY
Date ____________
Location _____________
GENERAL DATA
Patient Information
Name ______________________________________________ Age (Y/M) __________ Birthdate (MM/DD/YY)
_____________
Address ___________________________________________ Sex [ ] Male [ ] Female Religion
__________________________
Informant _____________________ Relationship to Patient ________ Is the informant the main care provider? [ ] Yes [ ] No

PRESENT ILLNESS
Chief Complaint ____________________________________________________________________________________________
Details Prior to Consult/Admission

HISTORY OF PRESENT ILLNESS

Location _____________________ Radiation ____________________ Quality _______________ Severity/Intensity __________
Timing ______________________ Duration ________________ Frequency ________________ Frequency _________________
Aggravating Factors ____________________________________ Alleviating Factors ___________________________________
Medication(s) Taken, if any ____________________ Date Started __________ Dosage _________ Frequency _____________
Associated Symptoms/Other Significant Information

PAST MEDICAL HISTORY

Past Illnesses (Adult/Pediatric)
Date/Age Occurred Details (Consult/Hosp/Surg) Date/Age Occurred Details (Consult/Hosp/Surg)

Did patient receive blood transfusion? [ ] Yes [ ] No If yes, when? _____________ *Include allergies, if applicable.

Gestational History (Pediatric)

Age of Mother During Pregnancy _______ Parity* ________ Health Status _____________ Nutrition ___________________
Were pre-natal check-ups done? [ ] Yes [ ] No If yes, frequency ___________________ Alcohol Use? [ ] Yes [ ] No
(On alcohol use, if applicable) When? _____________ Frequency _____________________ Tobacco Use? [ ] Yes [ ] No
(On tobacco use, if applicable) What kind? ____________ Frequency (packs/day) __________ Drug Use? [ ] Yes [ ] No
(On drug use, if applicable) What kind? ____________________ Frequency ___________ Needle Involvement [ ] Yes [ ]
No Other Significant Information/Overall Impression of Pregnancy (Psychosocial)

*For parity, know the no. of pregnancies, no. of live births, no. of abortions/miscarriage (induced/spontaneous)

Birth History (Pediatric)

Manner of Delivery (e.g., NSVD, C/S, Vacuum, Breech) ___________ Labor Time ______________ Maturity ______________
APGAR Score __________ Attending Person (e.g., physician, midwife, hilot) ______________ Place of Birth _____________
Ask about unang yakap:
Feeding History (Pediatric)
Type of Feeding ___________________ Frequency _____________________ Solid Food Started ________________________
Feeding Difficulties, if any _________________ Overall Impression of Child’s Appetite ________________________________
Patient Name _______________________________________________________________________________________________

Immunizations (Pediatric)
BCG ([ ] Yes [ ] No Date ___________) DPTV ([ ] Yes [ ] No Date ___________) Polio ([ ] Yes [ ] No Date ___________)
Hepatitis A ([ ] Yes [ ] No Date ___________) Hepatitis B ([ ] Yes [ ] No Date _______) Tetanus ([ ] Yes [ ] No Date _____)
Chickenpox ([ ] Yes [ ] No Date ___________) MMR ([ ] Yes [ ] No Date
___________) HPV ([ ] Yes [ ] No Date _______)
Other Vaccinations __________________________________________________________________________________________
*if completed all – completed primary health care immunization
Untoward/Adverse Reactions, if any

Growth and Development (Pediatric)

Supply the age when it first occurred:
Social Smile ____Raise Head____ Sat alone____ Pulled up_____ Crawled ____ Rolled Over_____ walked alone____ Talked meaningful word
or sentences ____ toilet trained____
Other Significant Developmental Milestones ____________________________________________________________________
*f too unremarkable say at par with age
Occupational and Environmental History (Adult/Pediatric)
Living Conditions (No. of pax in home, location of home, describe the type of house, etc.)

Source of Drinking Water ________________________ Common Mode of Food Preparation ___________________________

Source of Tap Water ____________________________ Toilet Type and Location _____________________________________ Nature of
Work _______________________ Duration of Service _______________ [ ] Permanent/Regular [ ] Contractual/JO Are PPEs (personal
protective equipment) necessary in your field of work? [ ] Yes [ ] No Is PPE being used? [ ] Yes [ ] No

Social History (Adult)

Tobacco (Vape use is included)
[ ] Never smoked [ ] Smoked, but rarely (When? _______) [ ] Quitted (Quit Date _________ Packs/Day ______ Years ____)
[ ] Currently Smoke (Packs/Day ______ Years ____) Type of Tobacco __________________ Interest to Quit? [ ] Yes [ ] No For
vape: How long can you consume one container of vape? _______________ Duration of vape consumption ________

Drug Use
Do you/have you use(d) recreational drugs? [ ] Yes [ ] No
If yes, what kind? ________________ How often? _____________________ Were needles involved? [ ] Yes [ ] No

Alcohol
Alcohol Consumption [ ] Yes [ ] No Frequency [ ] Never [ ] Occasionally [ ] Regularly Average Drinks/Week (include kind,
volume) ________________________ Is alcohol use a concern for you/others? _______
Sexual and Gynecologic History
Sexually Active? [ ] Yes [ ] No No. of Sexual Partners _______ Current Partner(s) is/are [ ] Male [ ] Female [ ] Both Birth
Control Used _______________ History of Sexually Transmitted Diseases (STD)? [ ] Yes [ ] No [ ] Don’t Know
( For STDs) If yes, what kind? _______________________ Interest to be screened for STD/HIV? [ ] Yes [ ] No

For females:
Age of Menarche (if menopause, indicate age of last menstruation) _____________ Regularity of flow _________________
Duration of period ___________________ Experience of menstrual cramps [ ] Yes [ ] No Frequency ____________________

Exercise (Adult)
Do you exercise? [ ] Yes [ ] No How often? [ ] Daily [ ] 4-6x/week [ ] 1-3x/week [ ] Less than once a week Exercise Form
(e.g., jogging, cycling, swimming, weights) ________________________________________________________
Psychosocial History (Adult/Pediatric)
Interaction (Pediatric: e.g., neighborhood, desire to be friends with others of the same age, difficulty making friends)
Patient Name _______________________________________________________________________________________________

Hobbies/Life Experiences (achievements [for pediatric], abuse, death, accidents, etc.)

Personal Relationships (teens/pre-teens)

Socioeconomic Status (Adult)

Marital Status [ ] Single [ ] Married [ ] Separated [ ] Widow Occupation __________________ No. of children _______
Is/are you child(ren) living with you? [ ] Yes [ ] No Who lives at home with you? _______________________________
Educational Attainment [ ] Grade School Graduate [ ] High School Graduate [ ] College [ ] Graduate School [ ] None
Foreign Travel? [ ] Yes [ ] No Frequency ____________ Last Travel Date ______________ Location _________________
For pediatric patients of school age; School attended _________________________________________________________

Family History
Genogram (Note the genetic influences/heredo-familial diseases, deaths [including the cause and year of death])

Legend:
☐ Male Female  Patient ✖ Deceased P Bread Winner

Common hereditary diseases: alcoholism, allergies (indicate), anemia, arthritis, asthma, birth defects (indicate), cancer
(indicate), colon polyps, depression, diabetes (indicate type), genetic diseases (indicate), glaucoma, high cholesterol,
heart disease, kidney diseases, migraine-induced headaches, osteoporosis, rheumatoid arthritis, seizures, stroke, thyroid
disorders, tuberculosis

Patient Pledge:

I hereby declare that the information I have provided is accurate and factual to the best of my ability and memory. It is
assured that the medical student handling my case shall guarantee me with utmost privacy and confidentiality.

_____________________________________________________ ________________________________
Patient Signature Over Printed Name Date Signed
 REVIEW OF SYSTEMS

General: ()unusual weight changes Skin: ( )rashes

() unusual weakness ( ) lumps
() fever ( ) sores
() changes in appetite ( ) pruritus
() easy fatigablility ( ) acne
( ) dryness
( ) changes in color
( ) Hair loss
HEENT: Head Eyes
( ) headache ( ) visual difficulties
( ) dizziness ( ) lacrimation
( ) discharges
( ) redness
( ) excessive tearing
( ) spots or specks
Ears Nose Throat
( )hearing difficulties ( ) nasal stuffiness ( ) dentures
( ) tinnitus ( ) discharge ( ) bleeding gums
( ) vertigo ( ) itching ( ) sore tongue
( ) fullness ( ) pain ( ) cavities
( ) pain ( ) rhinitis ( ) sore throat
( ) discharges ( ) sinusitis ( ) mild hoarseness of voice
Neck: ( ) swollen glands Breasts: ( ) pain
( ) swollen lymph nodes ( ) lumps
( ) pain ( ) nipple discharges
( ) stiffness
( ) thyroid condition
Respiratory: ( ) cough Cardiovascular: ( ) orthopnea
( ) wheezing ( ) cyanosis
( ) dyspnea ( ) chest pain or discomfort
( ) tachypnea ( ) palpitations
( ) chest pain or discomfort ( ) fainting spells
( ) easy fatigability
Peripheral ( ) color changes Gastrointestinal: ( ) nausea or vomiting
vascular: ( ) bleeding manifestations ( ) abdominal pain
( ) pain in defecation
( ) blood in stool
( ) hemorrhoids
( ) diarrhea
( ) flatulence
( )constipation
( )food intolerance
( )pica
Genitourinary: ( ) frequency Musculoskeletal: ( ) muscle or joint pains
( ) urgency ( ) edema
( ) pain on urination ( ) Limitation of movement
( ) incontinence ( )stiffness
( ) herniation ( )limping
( ) discharges
( ) amenorrhea
( )itching
Psychiatric: ( ) nervousness Neurologic: ( ) changes in attention or speech
( )tension ( ) fainting
( ) depression ( )pins and needles
()tingling
() tremors
()seizures
Hematologic: ( ) easy bruising Endocrine: ( ) heat intolerance
( ) bleeding ( ) excessive sweating
( )pallor ( ) excessive thirst and hunger
( ) thyroid trouble