Date: Informant:

History Taken by: Reliability:

IDENTIFYING DATA (Residents want a chief complaint directed History & PE)
Name:
Age: Gender: Civil status:
Birthdate: Birthplace:
Present Address:
Nationality: Occupation: Religion:
# of times admitted to this Hosp: Name of Hosp: Date Admitted:
CHIEF COMPLAINT

HPI

PMH
Childhood diseases: Mumps, Measles, Chicken pox, and German measles
Immunizations received:
Adult past Illnesses:
a) Medical:
b) Surgeries:
c) Accidents & Injuries:
d) Gynecologic:
e) Medications:
f) Blood Transfusion:
g) Allergies:
h) Psychiatric:
FMH (age, time of death, COD)
Father:
Mother:
Siblings:
Children:
Grandparents:
Heredo-familial disease:
Stroke, cancer, HPN, DM, Heart Disease, Blood disorders, Allergies, Arthritis, Obesity, Alcoholism,
Psychiatric, Seizure disorder, Kidney disorder
Communicable:
Tuberculosis, STI
PSH
Educational attainment:
Marital status:
Occupational history
 Nature of work:
 # Hours of exposure to hazards:
 Safety measurements used:
Financial resources:
Living conditions
 Source of water:
 Waste disposal:
Relevant travel history:
Habits
 Sleep & Rest pattern:
  Nutritional and Elimination:
 Smoking history
 # Sticks/Day:
 # Pack years:
 History of Alcohol and Coffee intake
 Age started drinking:
 Type:
 Quantity:
 Frequency:
 Illicit drug use:
Self-care
 Activities:
 Exercise:
Sexual History
 Exposure and History STI:
 # of Partners:
MOH (FEMALE)
Age Menarche:
 Regularity:
 Interval:
 Duration:
 Amount:
LMP:
Use of Hormonal Replacement:
Gravity:
Parity :
Manner of Deliver: Spontaneous, Cesarean section, Forceps Extraction
Use of Birth Control methods:
ROS
VITAL SIGNS
BP:
CR:
RR:
TEMP:
WEIGHT:
HEIGHT:
BMI: