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Internal Medicine HISTORY

I. PATIENT’S PROFILE Vomiting: Associating S/S:
A. GENERAL DATA (Time:_____) o Nausea? _______________________________
NAME: _________________________ o Sporadic? _______________________________
AGE: __________ SEX:____________ o Postprandial? _______________________________
RACE: _________ RELIGION:_______ o Projectile? _______________________________
CIVIL STATUS: ___________________ Amount of vomitus: _________ _______________________________
OCCUPATION: ___________________ Describe vomitus: _______________________________
ADDRESS: _______________________
_______________________________ o Yellowish-mucoid (stomach)
BDAY: __________________________ o Solid food? Laboratory results: (w/ units of measurement)
BPLACE: ________________________ o White, mostly saliva o CBC: _________________
DATE OF ADMXN: ________________ o U/A: _________________
PLACE OF ADMXN: ________________ Aggravating: o Stool exam: _____________
o Sitting up? Position: ______
II. CHIEF COMPLAINT: o Lying down? Pertinent Neg: __________________
o Carrying heavy objects? _______________________________
III. HISTORY OF PRESENT ILLNESS o Flashing lights? _______________________________
Onset: _________________________ o Walking? _______________________________
Nature/ Char: o Talking? _______________________________
Fever: o Eating? _______________________________
Relieving: _______________________________
Temperature:______°C
o Lying down? Effects on:
o Intermittent
- Relieved by meds? o Warm/ cold compress? o Work:________________
Minutes: ____________ o Lifestyle: _______________
goes down to temp: ______°C
o Physiologic fxn: ___________
for: ____ hours
Meds:

IV. PAST HISTORY
o Continuous
Dosage Generic Brand name Childhood illnesses:
o Remittent # of tab, name
mg, hours, o Measles (tipdas): ______y.o.
Pain: (headache, etc) # of o Chickenpox (hangga): ___y.o.
dosages:
Pain score: _____ out of 10 o Mumps (bayu-ok): ______y.o.

Location: ______________________ o Smallpox (bulutong): ____y.o.
1.
o Transferred? o Dengue: ______y.o.

to: ______________ Immunizations:
2.
o Constant? o BCG
o DPT
3.
o Radiating?
o MMR
o Throbbing? o Hep B
o Colicky? (kumot-kumot, on & off)
4. o Pneumococcal

o Pulsating? (eg. Migraine) o OPV
5. o Health center?
o Gnawing? (ngut2x eg. Hunger pangs)
o Aching? (cont. kumot) o Private clinic?
Adult Illnesses:
o Burning? (hapdos)
o Sharp? Medical:
o Dull? (ngol2x, numb) RESPONSE TO MEDS: Yr/ Hospital Dx/ Prob Tx
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
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Smoking:
Psychiatric Disorders: - Since: ___________________
Surgical: o Extreme sadness? - Packs/day: ______________
Yr/ Hospital Dx/ Prob Tx o Suicidal? - Frequency: _______________
- PACKS/ YR ___________
Screening Tests: = (Age now - Age start )x(pack/day)
year results Sleeping habits: _________________
X-ray Eating patterns: _________________
Bowel Movements: _______________


Hep B Titer Urination:_______________________

Lipid Panel Exercise: ______________________
OB-GYNE: Allergies:
MENARCHE FBS o Drugs: ________________
o Food: _________________
Age: _____ Duration: _____________
HBA1c o Environmental: ___________
Character of Flow: Light/ Mod/ Heavy
Pads/day:_______________________

SUBSEQUENT MENSES Spouse:
o DM
Regular:_________________________ - Occupation: _____________
o Hypertension
Pads/day: _______________________ - Age: ________
o Arthritis
Duration: _______________________ - Health: _______________
o Heart Dses
Interval: ________________________
o TB
Days of Menstrual Cycle: ___________ Children:
o Cancer
Associating Symptoms: 1st 2nd 3rd
o Asthma
Dysmenorrhea: _____ Pain Scale: ____ o Anemia Age
Intervention: ____________________ o Stroke sex
________________________________ o Kidney dses health
Meds: ________________________

MENOPAUSE V. PERSONAL & SOCIAL HISTORY VI. FAMILY HISTORY
Age: ______ HRT used: ____________ FATHER:
Occupation: ___________________
_______________________________ Age: _____ Health: ______________
Education: ____________________
Menopausal S/s: _______________________________
Religion: (Refer to Gen. Data)
- Hot flashes ( ) _______________________________
Hobbies: _______________________
- Irritability ( ) Meds: (Name/ Dose/ Compliance)
Home situation:
- Fatigue ( ) _______________________________
o Living alone
- Others: __________________ o Living with: _____________ _______________________________
_______________________________ MOTHER:
o Apartment
Age: _____ Health: ______________
o Own house
G( ) T( ) P( ) A( ) L( ) _______________________________
o In-laws house
_______________________________

G1 G2 G3 G4 Meds: (Name/ Dose/ Compliance)
HABITS
Year Alcohol ingestion: ________________ _______________________________
AOG - Since: ___________________ _______________________________
Duration - # of bottles: ______________ Rank in the family: _______________
of Labor
- Frequency: _______________ SIBLINGS: (Age/ Health/ Meds)
Method
of Del - Cut down: _______________ Rank
Place of - Annoyed: ________________ Age
Del
- Guilt feelings: _____________ sex
Wt:
- Eye opener: ______________ health
Sex
- Stop: ____________________ meds
Cx: Heredofamilial Dse: ______________

_______________________________
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REVIEW OF SYSTEMS
General. Usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue
Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails
Head, Eyes, Ears, Nose, Throat (HEENT)
Head. Headache, head injury, dizziness, lightheadedness
Eyes. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights,
glaucoma, cataracts
Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids
Nose and sinuses. Frequent colds, nasal stuffiness, discharge, or itching hay fever, nosebleeds, sinus trouble
Throat. Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, last dental examination, sore tongue, dry tongue, frequent sore
throats, hoarseness
Neck. Lumps, “swollen glands”, goiter, pain or stiffness in the neck
Breasts. Lumps, pain or discomfort, nipple discharge, SBE
Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray, asthma, bronchitis, emphysema,
pneumonia, TB
Cardiovascular. Heart trouble, high BP, rheumatic fever, heart murmurs, chest pain or discomfort, palpations, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, edema, past ECG or other heart test results
Gastrointestinal. Trouble swallowing, heartburn, appetite nausea, bowel movements, color and size of stools, change in bowel habits, rectal
bleeding or black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas,
jaundice, liver or gallbladder trouble, hepatitis
Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones,
incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling
Genital.
Male hernias, discharge, from or sores on the penis, testicular pain or masses, history of STDs and their treatments, sexual habits, interest,
function, satisfaction, birth control methods, condom use, problems, exposure to HIV infection
Female age at menarche, regularity, frequency, and duration of periods, amount of bleeding, intermenstrual bleeding or after intercourse, LMP,
dysmenorrheal, premenstrual tension, age at menopause, menopausal symptoms, postmenopausal bleeding, vaginal discharge, itching, sores,
lumps, STDs and treatments, number of pregnancies, number and type of deliveries, number of abortions, complications of pregnancy, birth
control methods, sexual preference, function, satisfaction, problems, dyspareunia, exposure to HIV infection, if born before 1971, exposure to
diethylstilbestrol (DES) from maternal use during pregnancy
Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins
Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected joints, muscles, presence of any
swelling, redness, pain, tenderness, stiffness, weakness or limitation in motion or activity, duration & any history of trauma
Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”, tremors or other
involuntary movements
Hematologic. Anemia, easy bruising or bleeding, past transfusions and or transfusion reactions
Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size
Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant
GENERAL SURVEY
Level of consciousness: conscious/alert, confused, lethargic/somnolent, Sexual development : normal, precocious puberty, hypogonadism,
stupor/semi-coma, comatose virilism, delayed puberty
Mental state & mood: orientation to time, place and identity, coherent, Signs of distress: labored breathing, flaring of ala nasi, wheezing,
incoherent, cooperative, uncooperative, hostile, depressed, apathetic, coughing, sweating, anxious face, protectiveness of painful parts,
nervous fidgety movement
Gait: ambulatory, non-ambulatory, trunk posture, gait sequence, arm Physical appearance in relation to age: appropriate, younger, older
movement, hemiplegic, steppage, tabetic, parkinsonian, scissors
Posture: normal position, lordosis, kyphosis, scoliosis, decorticate VITAL SIGNS:
rigidity, decerebrate rigidity, opisthotonus BP: ___mmHg right/ left; arm/leg; sitting/supine
State of nutrition: underweight, emaciated, cachectic, normal, PR: ___bpm right/ left radial; regular normal force (or +2) :
overweight, obese, extremely obese weak, thready, strong, forceful, bounding
Habitus/Body build: mesomorphic, ectomorphic, endomorphic, sthenic, RR: ___cpm regular, silent, normal depth
asthenic, hypersthenic Temp: ___°C right/ left, axillary/oral/rectal
Stature/Height
Involuntary movements: tics, chorea, athetosis, dystonia, tremors Ht: ____cm
(resting, intention, postural) Wt: ____ kg
Speech: normal, hoarse voice, aphonia, slurred, scanning, echolalia

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