REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF MEDICINE

COMPREHENSIVE COMBINED HISTORY TAKING FORM

Hosipital: _______________ Dept: ___________ Date of Admission: ________________ Time of Admission: ____________

Date & Time of History: _____________________________________ Source of Referral: _______________________________

Source of History: ________________________________________________________________________ Reliability: ____________

I. General Data
Name: ________________________________________________________ Age: ______ Sex: ______ Civil Status: ______Nat’l:______
Birthday: __________________ Place of Birth: _______________Religion:______Occupation: _____________________________
Address: _____________________________________________ # of times admitted in hosp: ___________HCF:_______________

II. Chief Complaint

III. History of Present Illness

IV. Past History
A. Immunization: complete incomplete last tetanus shot
At birth: ( ) BCG,ID at ___ deltoid , booster at ___deltoid at ________
( ) Hepa 1, IM after birth/ ____ hours/days of life
6 wks: ( ) Hepa 2 _______________
( ) DPT 1, IM ________________
( ) OPV 1, oral ________________
10 wks: ( ) DPT 2 ________________
( ) OPV 2 ________________
14 wks: ( ) Hepa 3 _______________
( ) DPT 3 ________________
( ) OPV 3 ________________
9 m0s: ( ) Measles, SQ ______________

HBV: IM 3x (birth at 1 mo interval)

1st: _________ 2nd: _________ 3rd: __________
MMR: SQ (15 mo) Booster: (5-12 y.o.) ____________
Influenza: IM 3x (<6mo @ 2 mo interval
1st: ________ 2nd: _________ 3rd: __________
2x (6mo-1yr) ________________ 1x (>1yr) ______________ Booster (15mo) _______________

EPI: BCG, DPT, POLIO, MEASLES, HEPA B

Fully: BCG, DPT, POLIO,HBC-3 doses each; 1 dose MEASLEs

B. Allergies:

C. Drug Reactions:

D. Blood type & Transfusion Hx:

E. Smoking Hx:

F. Alcohol & Drug Use:

G. Childhood Illnesses
chicken pox mumps measles rubella rubeola streptococcal
scarlet fever rheumatic fever others:

H. Medical Problems & Hospitalization

heart dse cancer diabetes hypertension
obesity allergies arthritis tuberculosis
bleeding alcoholism mental d/o others:
 I. Medications
aspirin vitamins nasal spray laxatives others:

J. Surgical Problems, Accidents, & Hospitalizations

K. Obstetric/ Gynecologic
Age at menarche: ____________________
Regularity: ___________________________
Frequency: ___________________________
Duration of periods: _________________
Amount of bleeding: _________________
Bleeding between periods or after
intercourse: __________________________
Last menstrual period: ______________
G__P__(__-__-__-__)
T- A-
P- L-
NSVD-ceph: __________breech:__________C/S-___________________
Number of abortions (spontaneous and induced):
S-________________________________I-_______________________________
Complxn of
pregnancy:________________________________________________________
hospital RHU Home
Birth Attendant: _________________________________________________
Age at menopause: _______________________________________________
Menopausal symptoms: _________________________________________
Postmenopausal bleeding: ______________________________________

Sexual Partners & Age:

Sexual Activity:
Frequency: ________________________ Untoward S/Sx during sex: _______________________________________
Family Planning Methods:_____________________________________________________________________________
How long?_____________ Side effects?______________________________________________________________________
Cleaning Habits:_________________________________________________________________________________________
STD Hx:____________________________________________________________________________________________________

L. Psychiatric

IV. Family History

Name of Father: _______________________________________ Occupation:
Age: ___________ Occupation: __________________________ Medical History:

Name of Mother: _______________________________________ Occupation:

Age: ___________ Occupation: __________________________ Medical History:

Name of Spouse: _______________________________________ Occupation:

Age: ___________ Occupation: __________________________ Medical History:

Family Hx of Illness:
heart dse cancer diabetes hypertension
obesity thyroid arthritis tuberculosis
bleeding alcoholism mental d/o others:
Children/Siblings:

V. Personal and Social History

EDUCATION:
Highest level of education: School: problems in schooling

HOUSING STATUS:
Lives with:
Type: location:
Ventilation:  problems in housing
pets/domesticated  stray animals  manure mosquito stagnant water flies rats other insects
carpet dust stuffed toys
TOILET FACILITY:
Type: Located: inside outside communal Meters from House:
Meters from water source: Maintenance:
ELECTRICITY:
GARBAGE COLLECTION: open dumping burned communal
WATER SUPPLY:
DRINKING WATER source: WASHING WATER source:
Treatment:
COOKING FACILITY: : inside outside gas woodfire STORAGE:
MEALS(INCLUDE TIME): breakfast lunch dinner snack
Who cooks the food: Who buys the food:
TYPICAL DIET ON A NORMAL DAY (SNACK INCLUDED):

WATER INTAKE AND SOURCE:

cola coffee tea smoking

Father is a  smoker  alcoholic occupation:_______________ income:_____________

Mother is a  smoker  alcoholic occupation:_______________ income:_____________

PSYCHOLOGICAL
TYPICAL ACTIVITIES(WEEKDAY): Sleep: Wake: Naps:
TYPICAL ACTIVITIES(WEEKEND):

EXERCISE: HABITS:

sleep elimination eat grooming dressing

activities food preparation shopping transportation housekeeping
laundry communication dev. finances medications others:

INVOLVEMENT:
Church: Barangay: Others:
interacts well/friendly towards others participates in school does household chores
peer pressure 1 coitus and when:____________ reckless behavior:
st

Major stressor:
Coping pattern:
Observe:
verbalize appropriate emotions interaction with support person
congruence of verbal and non verbal behavior/expression
Who helps in times of need:
Effect of the client’s condition on the family (as verbalized):
family problems community problems
PATTERNS OF HEALTH CARE
Folk practitioner/Alternative
Herbalist
Tambalan
Dentist/Dental Hx Specialists:
Availability: health center:___________________________ adequate care/services
COMMUNICABLE DISEASES/COMMUNITY RISKS
TB Dengue Schistosomiasis CAP HIV
Radiation Smokers Drugs Others:

PEDIATRICS ADDITIONAL INFORMATION

Prenatal Hx
Pt. was born to a _____ y.o. G P ( - - - - ) mother who ( ) smoke at least ___ sticks per day, ( ) drinks alcoholic beverages
at least ____ glasses/bottles/gallons of _______ per drinking session during the whole course of pregnancy. ( ) prenatal check-up
started from ___ mos AOG to ____ mos AOG at _____________ conducted by a _____. She received ( ) TT__ vaccine, ( ) vit, ( ) FeSo4,
taken for ___ days/wks/mos. ( ) Maternal illness such as fever, cough & colds, UTI & others _________ during ____ mos AOG for
____days/weeks/months. ( ) Medication, self treated/prescribed meds of ________________ for ___________ illness taken at ____mos
AOG for ___days/wks/mos. ( ) Hx of exposure to radiation, ( ) abortion, ( ) hypogastric pain, ( ) persistent uterine
contractions, ( ) vaginal spotting/bleeding, ( ) watery vaginal d/c.

Birth Hx
Pt. was delivered pre-/full-/post- term w/ ___ AOG via _______ assisted by a ________ at _____________ in ____________ presentation w/
______ hrs/days of active labor. Umbilical cord was cut using a __________ sterilized/pre-boiled/ soaked with __________ & sloughed
off for ___days/wks. ( ) complications observed at the umbilical area such as foul-smelling/yellowish
color/erythema/pus/bloody/watery d/c. Umbilical stump was cleaned every _____ using a __________________.
 Neonatal Hx
Pt. was pinkish/pale/bluish/yellowish with a _______ cry, ( ) weak, ( ) vigorous movements. ( ) Dyspnea, ( )
Fever/Convulsions, ( ) bleeding. ( ) First stools [Meconium], ___________ in color, ____________ in consistency w/ __________ odor
after ____ hrs and ( ) urine after _____ hrs of life.

Feeding Pattern
Pt. was breastfed/bottlefed _____ hrs after birth, every ____ hrs/min with ____min duration on each breast. Pt. was bottle fed at
____mos., supplemental feeding / solid food was introduced at ____ mos consisting of ___________________________. ( ) Vit given at
____ mos, ____mL OD/BID.

24 HOUR DIET RECALL:

Before onset of illness

Food Intake Number of Serving Calorie

Breakfast

Snack

Lunch

Snack

Dinner

Total caloric intake per day

Ideal calorie intake per day

During onset of illness

Food Intake Number of Serving Calorie

Breakfast

Snack

Lunch

Snack

Dinner

Total caloric intake per day

Ideal calorie intake per day

 GROWTH & DEVELOPMENT
AGE GROSS MOTOR ADAPTIVE FINE MOTOR LANGUAGE PERSONAL SOCIAL

BEHAVIOR
The pt. is ( ) sleepy, ( ) quiet, ( ) apathetic, ( ) playful, ( ) aggressive, ( ) moody, ( ) irritable, ( ) friendly. Sleeping habits
wakes up at ____ am & sleeps at ____ pm. ( ) Nail biting. ( ) Thumbsucking at ___mos to ___mos.

VI. Review of Systems

1. GENERAL
Usual weight: ________ ____ Weakness ____ Fever
Recent Weight Change: ________ ____ Fatigue
2. SKIN
____ Rashes ____ Dryness
____ Lumps ____ Changes in color
____ Sores ____ Changes in hair or nails
____ Itching ____ Changes in size or color of moles
3. HEENT
a. HEAD
____ Headache ____ Dizziness
____ Head injury ____ Light headedness

b. EYES
Last examination: ____________ ____ Excessive tearing ____ Flashing lights
____ Glass or contact lens ____ Double or blurred vision ____ Glaucoma
____ Pain ____ Spots ____ Cataracts
____ Redness ____ Specks

c. EARS
____ Tinnitus ____ Earaches ____ Discharge
____ Vertigo ____ Infection ____ Use of hearing aids
 d. NOSE AND SINUSES
____ Frequent colds ____ Itching ____ Nosebleeds
____ Nasal stuffiness ____ Hay fever ____ Sinus trouble
____ Discharge

e. THROAT (MOUTH AND PHARYNX)

Last Dental Examination: __________________ ____ Dry mouth
____ Bleeding gums ____ Frequent sore throats
____ Dentures ____ Hoarseness
____ Sore tongue
4. NECK
____ Goiter ____ Pain
____ Lumps ____ Stiffness
5. BREASTS
____ Lumps ____ Nipple discharge
____ Pain or discomfort Self examination practices: __________________
6. RESPIRATORY
____ Cough ____ Asthma
____ Sputum color and quantity ____ Bronchitis
____ Hemoptysis ____ Emphysema
____ Dyspnea ____ Pneumonia
____ Wheezing ____ Tuberculosis
____ Pleurisy Last chest x-ray: ________________
7. CARDIOVASCULAR
____ High blood pressure ____ Orthopnea
____ Rheumatic fever ____ Paroxysmal nocturnal dyspnea
____ Heart murmurs ____ Edema
____ Chest pain or discomfort ____ Results of past ECG
____ Palpitations Other cardiovascular tests: _____________
____ Dyspnea
8. GASTROINTESTINAL
____ Trouble swallowing ____ Rectal bleeding or black or tarry stools
____ Heartburn ____ Hemorrhoids
____ Appetite ____ Constipation
____ Nausea ____ Diarrhea
____ Bowel movements ____ Abdominal pain
____ Stool color and size ____ Food intolerance
____ Change in bowel habits ____ Excessive belching or passing of gas
____ Pain with defecation BM:
9. PERIPHERAL VASCULAR
____ Leg cramps ____ Swelling in calves, legs or feet
____ Varicose veins ____ Color change in fingertips or toes during cold weather
____ Past clots in the veins ____ Swelling with redness or tenderness
10. URINARY
____ Frequency of urination ____ Urinary infections
____ Polyuria ____ Kidney or flank pain
____ Nocturia ____ Kidney stones
____ Urgency ____ Ureteral colic
____ Burning or pain during urination ____ Suprapubic pain
____ Hematuria ____ Incontinence
 UO: Males:
____ Reduces or caliber force of the urinary system
____ Hesitancy
____ Dribbling
11. GENITAL
Males Females
____ Hernias ____ Dysmenorrhea
____ Discharge from or sores on the penis ____ Premenstrual tension
____ Testicular pain or masses ____ Vaginal discharge
____ Scrotal pain or swelling ____ Itching
____ History of STI and their treatments ____ Sores
____ Sexual habits ____ Lumps
____ Birth control methods ____ STI and treatments
____ Condom use
____ HIV infection concerns

12. MUSCULOSKELETAL
____ Muscle or joint pain ____ Gout
____ Stiffness ____ Back-ache
____ Arthritis
13. PSYCHIATRIC
____ Nervousness ____ Depression
____ Tension ____ Memory change
____ Mood ____ Suicide attempts
14. NEUROLOGIC
____ Changes in mood, attention or speech ____ Weakness
____ Changes in orientation, memory, insight or ____ Paralysis
judgment ____ Numbness or loss of sensation
____ Headache ____ Tingling or “pins and needles”
____ Dizziness ____ Tremors
____ Vertigo ____ Other involuntary movements
____ Fainting ____ Seizures
____ Blackouts

15. HEMATOLOGIC
____ Anemia ____ Past transfusions
____ Easy bruising ____ Transfusion reactions
____ Easy bleeding

16. ENDOCRINE
____ Heat or cold intolerance ____ Polyuria
____ Excessive sweating ____ Change in glove or shoe size
____ Excessive thirst or hunger
VII. Physical Examination
1. General Survey
Patient was examined: __sitting __lying __cuddled
__conscious, __lethargic, __stuporous, __comatose
__sleepy, __alert, __coherent, oriented to: __time,
__place, __person
__cooperative, __febrile, __nourished, __groomed,
__CR distress
__well developed, __endomorph, __ectomorph,
__mesomorph,
with the following vital signs:

Vital Signs Actual Ideal

Blood Pressure (BP)

Temperature (T)

Pulse Rate (PR)

Respiratory Rate (RR)

Anthropometric Data Actual Ideal Z-Score

Head Circumference

Chest Circumference

Abdominal Circumference

Mid Arm Circumference

Length/ Height

Weight
Formula Result Interpretation
(actual wt/ideal Normal: > 90%
Wasting wt for age) x 100 Mild: 80-90%
Mod: 70-80%
Severe: < 70%

(actual ht/ideal Normal: > 95%

Stunting ht for age) x 100 Mild: 90-95%
Mod: 80-90%
Severe: < 80%
2. Integument
 Skin is __warm, __cold; __dark __fair in color; __dry, __moist; __good skin turgor
 __petechiae, __ecchymoses __rashes, __active lesions, __hypo/hyperpigmentation,
__cyanosis: central/peripheral, __jaundice; __edema: pitting/nonpitting on:_______________
 Nails are __pale in color, capillary refill __ 2s; __clubbing
3. Head
Skull is __atraumatic, __symmetric, __masses; temples: __depressed; __ant. Fontanelle_____,
__post. Fontanelle_____, __bulging fontanels, __tensed fontanels, __pulsating
Fontanels: A=2.5-4cm 12-18 mos
P=0.5-1cm 6-8 wks
Hair is __black __brown in color, __straight, __curly, __equal distribution, __fine __coarse,
__intact, __alopecia, __flag sign, __lice infestation, __dandruff
__active lesions __tenderness
4. Eyes
Eyebrows are __symmetrical, __scars __active lesions
Eyelashes: __Fine __black __oriented:outwards/inwards
Eyelids: __edema, __tenderness __lid lag
__Anicteric sclera __hemorrhage __ulceration
__Clear cornea __ulceration
__Pupils equally round, __reactive to light and __accommodation; diameter:_____
EOM __intact
5. Ears
__Symmetrically __aligned
__Firm pinnae __tenderness
__Intact tympanic membranes and canals; __impacted cerumen,
__active lesions
__Good hearing acuity; __webers __rinne’s; AC__BC

6. Nose and Sinuses

__Pale mucous membrane; __epistaxis, __lesions
Septum __ midline
__nasal discharges, __nasal flaring __congestion

7. Mouth and Throat

__cyanosis __angular deviation __
__complete set of teeth __carries; #:___
__fissures, __ulcerations, __bleeding __sores in the
mucosa, __tongue __gingiva
__Uvula at midline; __Tonsils not enlarged
__Pale soft and hard palate
8. Neck
Trachea __midline
Thyroid gland __palpable __moves with deglutition
__palpable lymph nodes __lumps; __engorged veins,
__visible pulsations

9. Breasts
__discoloration __dimpling, __discharges of
both breasts
__Everted nipples __palpable lymph nodes,
__lumps __tenderness of both breast.
Tanner Stage:__

10. Chest and Lungs

Thorax __symmetric, __lesions __masses __lagging
__supraclavicular __intercostal retractions
__tenderness __Symmetrical chest expansion
__Unimpaired tactile fremitus in all lung fields.
__Resonant in all lung fields of both anterior and
posterior chest
__adventious(location): __crackles __wheezing

11. Heart
__Adynamic heart __precordial bulging
__Thrills __heaves __lumps __tenderness
PMI at __ 5th ICS LMCL; JVP at __cm taken from the sternal
angle.
__murmur: __diastolic __systolic__ at ___area
__Heart rate synchronous with pulse rate; HR=___bpm
__pericardial rubs __carotid bruits.

12. Abdomen
__Protuberant __full __flat __scaphoid abdomen; abdominal girth of
__cm __ascites
__visible peristalsis __pulsations __lumps __nodules __scars.
__Soft to touch __Liver palpable; liver span of __cm
__direct or __rebound tenderness __guarding
Spleen is __palpable; splenic span of__cm
__Kidneys, __pancreas, __gallbladder are palpable.
__tympanitic __dull in quadrant:____
 __shifting dullness, __succussion splash; __rovsing __obturator; __fluid wave
__Normoactive bowel sounds at __/min

13. Extremities
__Symmetrical __equal in length and size __edema on ______ extremities
__deformities, __cyanosis, __atrophy; __tenderness
Pulse: __radial __popliteal __Dorsalis pedis
14. Back and Spine
__abnormal deviation __kyphosis __lordosis __bulging across the length of the spine
__paravertebral tenderness __mass; __kidney punch

VIII. Neurologic Examination

1. Mental Status Examination
The patient is __conscious __lethargic __stupor __coma
__attentive and cooperative; __active __inactive,
__quiet; __oriented to __time __place __person
__well groomed __affect within normal range __Speech
is clear __thought process intact
__ responds appropriately;

2. Cranial Nerves
I: __ anosmia
II: pupils __mm in diameter, __symmterical, __equal __briskly reactive to __direct and
__consensual light stimulation
III, IV, VI: __ intact EOM __up __down __medial __lateral
V: __ corneal reflex, __ intact sensation to hot and cold __to touch __to pain
VII: able to __smile and __frown, __puff cheeks; __symmetry when crying
VIII: __hearing not impaired; __whisper; __responds to verbal stimuli
IX, X: able to __ swallow, __intact gag reflex
XI: __able to turn head side to side and against resistance, __shrugs shoulders
XII: __protrudes tongue __deviation
1. Motor Function
Muscle strength is __full bilateral; Muscle
bulk and tone __normal __atrophic
__limitations in ROM
Grade (5/5): __RUE __LUE __RLE __LLE
3. Sensory
__withdraws hand where pain stimulus is applied __ intact stereognosis, __intact position
sense, __intact 2-point discrimination, __graphestesia
4. Reflexes
Primitive:
__ Moro reflex,
__Tonic-neck reflex,
__Babinski reflex,
__Ankle clonus

5. Cerebellar
__rapid alternating movement of hands __extraneous movements _-tremors __tics
__Posture is normal __able to do pronation and supination __ able to do finger to nose test
__Romberg’s

6. Meningeal
__ nuchal rigidity, __ Kernig’s sign, __ Brudzinski’s sign

7. ANS
__excessive sweating __urinary incontinence