MCU-FDT MEDICAL FOUNDATION HOSPITAL

OUT PATIENT SERVICES

DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY

Family Name Given Name Middle Name Age Date:

Time:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

OB GYNE HISTORY PAST MEDICAL HISTORY FAMILY HISTORY PERSONAL/SOCIAL HISTORY

FMP _____ __ ALLERGY __ HPN __ NONE __ HPN SMOKING HISTORY

LMP _____ __ BRONCHIAL ASTHMA __ DM __ DM __ CANCER ALCOHOL CONSUMPTION
PMP _____ __ CONVULSION __ TB __ HEART DISEASE DIET
PMS _____ __ HEART DISEASE __ OTHERS
G __ P __ ( __,__,__,__) __ OTHERS

REVIEW OF SYSTEMS
HEADACHE ___ BLURRING OF VISION ___ DYSPNEA ___ CHEST PAIN ___
DIZZINESS ___ VISUAL LOSS ___ WHEEZING ___ PALPITATIONS ___
MIGRAINE ___ DECREASED HEARING ___ TACHYPNEA ___ EASY FATIGABILITY ___
OTHERS TINNITUS ___ COUGH ___ ORTHOPNEA ___
NOSE BLEED ___ HEMOPTYSIS ___ PEPTIC ULCER DISEASE ___
OTHERS OTHERS

HEMATEMESIS ___ NECK PAIN ___ PARESTHESIA ___ FEVER ___

CONSTIPATION ___ JOINT PAIN ___ WEAKNESS ___ CHILLS ___
HEMATOCHEZIA ___ BACK PAIN ___ SYNCOPE ___ JAUNDICE ___
ABDOMINAL PAIN ___ MUSCLE PAIN ___ CONVULSION ___ MALAISE ___
DYSPEPSIA ___ OTHERS DEPRESSION ___ OTHERS
VOMITING ___ HALLUCINATION ___
DIARRHEA ___ OTHERS
MELENA
OTHERS

VITAL SIGNS ANTHROPOMETRICS

PR ___ RR ___ BP ___ TEMP ___ PAIN SCALE ___ WEIGHT ___ HEIGHT ___ BMI ___

PHYSICAL EXAMINATION;

GENERAL SURVEY:

OTOSCOPY
 RHINOSCOPY

ANTERIOR POSTERIOR

ORAL CAVITY INDIRECT LARYNGOSCOPY

HEAD AND NECK

/
CLINICAL IMPRESSION:

MANAGEMENT:

DISPOSITION: History and PE done by: Countersigned by:

____ Admitted ______________________ ,MD

____ Discharged with prescription Signature over printed name
and instructions Resident-in charge

Date of follow-up ______________________ ,MD

Signature over printed name
____ Home against medical advice Consultant on Duty