Name of Patient: Age: Sex: Status: Religion:

Address: Case Number:

Attending Physician: Rm/Ward: Date of Admission:

CLINICAL HISTORY
Chief Complaints:

Brief History of Present Illness:

History of Past Illness and/or Hospitalization

Yes No Yes No Yes No
ASTHMA PEPTIC ULCER DISEASE CANCER OR TUMOR
HYPERTENSION RENAL DISEASE PREVIOUS SURGERY
TUBERCULOSIS HEAD AND SPINAL INJURIES OBSTETRICAL PROBLEMS
CARDIOVASCULAR DISEASE SEIZURE DISORDER GYNECOLOGIC PROBLEMS
RHEUMATIC FEVER NERVOUS DISORDER EXTENSIVE CONFINEMENT
DUE TO ILLNESS/INJURY
HEPATITIS PSYCHIATRIC DISORDER PERMANENT DEFECTS DUE
TO ILLNESS AND/OR INJURY
GASTROINTESTINAL MUSCULAR DISEASE OTHERS
PROBLEMS
If the answer to any of the above is “YES”, please explain/specify in this space provided:

Family History Average per day:

Number of bottles:
Alcohol: YES NO
Number Of sticks:
Tobacco/ YES NO
Cigarette:
Number of cups:
Tea or YES NO
coffee
Social History Allergy:
Specify:
Food: YES NO

Specify:
Drugs: YES NO
 PHYSICAL ASSESSMENT
Blood Pressure (mmHg) Heart Rate (bpm) Weight (kg)
Temperature ( C) Respiratory Rate (cpm) Height (cm)
General Mentation: CONSCIOUS COHERENT
GENERAL APPEARANCE: Orientation: TIME PLACE PERSON
Others (specify):

Hydration: GOOD POOR Turgor : GOOD POOR SENILE

SKIN, HAIR, & NAILS Appearance: PINKISH CYANOTIC PALOR
ABNORMALITY (Specify):

Conjunctivae: PINKISH PALE ICTERIC

Ear: TINNITUS DISCHARGES
HEAD, EYES,EARS,NOSE, & THROAT: Nose & Throat: TONSILLOPHARYNGEAL CONGESTION
ABNORMALITY (Specify):

Expansion: EQUAL Breath Sounds: CLEAR VESICULAR

UNEQUAL RONCHI WHEEZE
CHEST/ LUNGS: CRACKLES
ABNORMALITY (Specify):

Heart Sounds: NORMAL DISTINCT GALLOP MURMUR

CARDIOVASCULAR Rate: NORMAL BRADYCARDIA TACHYCARDIA SKIP BEATS
ABNORMALITY (Specify):

Bowel Sounds: NORMOACTIVE HYPERACTIVE HYPOACTIVE

Shape: FLAT GLOBULAR DISTENDED
GASTROINTESTINAL Tenderness: POSITIVE NEGATIVE MASS, specify: ________________
ABNORMALITY (Specify):

KPS: NEGATIVE POSITIVE

GENITOURINARY ABNORMALITY (Specify):

Strength: Edema: Range of Motion:

NEGATIVE ACTIVE PASSIVE
MUSCULOSKELETAL & EXTREMITIES: POSITIVE Full Full
OTHERS: Limited Limited

Sensation OTHERS: Reflexes OTHERS:

NEUROLOGICAL:

Admitting Impression:

Reason for Admission:

_____________________________________
DOCTOR’S NAME & SIGNATURE