Name of Patient: _________________ Hospital: _____________________

Informant: ______________________ Department: __________________

Reliability: _______________________ Preceptor: ____________________
Historian: _______________________ Date Taken: ___________________
Group No.: _____________________ Date Submitted: _______________

CLINICAL HISTORY
I. GENERAL DATA
Name: ______________________ Age: _______________________
Civil Status: _________________ Nationality: _________________
Sex: _______________________ Religion: ___________________
Birth Place: _________________ Birth Date: _________________
Address: ____________________ Handedness: _______________
Nth visit: ___________________ Date and Time of consultation: ___________

II. CHIEF COMPLAINT: ________________________________________

III. HISTORY OF PRESENT ILLNESS

_______ PTA Symptom: ___________________________
Onset: ______________________________
Location: radiating/point where____________________________
Duration: does it recur____________________________
Character: constant/intermittent/constricting/squeezing ___________________________
Frequency: __________________________
Intensity: ____________________________
Associated factors: DOB/SOB/Orthopnoea ______________________________
Aggravating factors: meal/position/defecation/drugs/effort ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
IV. PAST MEDICAL HISTORY
HPN:________ DM: ________ Asthma: _________ TB: _________
Cardiac dse: _____ Cancer: ____ Allergies: ________

Signs/ symptoms:
How diagnosed:
_______ PTA Hospitalization:
Medications and compliance:
Follow up consultation:

Signs/ symptoms:
How diagnosed:
_______ PTA Hospitalization:
Medications and compliance:
Follow up consultation:

History of surgery: dates/indications/types of operations_________________________________________________

Hospitalizations: _________________________________________________________
Accidents/Injuries: ______________________________________________________________
Allergies: _______________________________________________________________
Immunization status: TT/DPT/MMR/Polio/Influenza/Varicella/HepaB____________________________________________

V. PERSONAL AND SOCIAL HISTORY

Education: __elementary __high school __college __post-grad __vocational course: ________________

Occupation: ____________________ hours of work per day: _____________________
Usual daily activities: _____________
Financial Status: _______ Source: _______ Income meet needs: yes no
Housing: # of household members: _________
House: __concrete __wood others: _______one storey /two storey
__good lighting __good ventilation
Toilet: ___flush type ___pour flush
Diet: ________________
Usual meal: _________ when: if hungry/scheduled____________Where_____________Who_______________
Estimate of Fluid intake: ________ 24 hr-diet recall: __________________________
Exercise:type/duration/frequency___________________
Water Supply: __deep well __NAWASA others: _______
Drinking water: boiled? yes no
Garbage disposal: segregate? __ yes __ no collected? __yes __no (if yes, when? ___________)
Risk habits:
Smoking: age started: ____ age stopped: ____ cig/day: _____ pack/yrs: _____
Alcohol drinking: age started: ____ age stopped: ____ frequency: ______ bottles: _______
Cola/Coffee: Estimated amount: __________ frequency:________
Medications and Substances:
Prescribed drugs: ______________________ Unprescribed drugs: _______________________
Purposes: ______________________ Dosage: __________ Frequency: __________
Vitamins/herbal supplements:enumerate/mg./frequency_________

VI. FAMILY HISTORY

Ask the following diseases (specify who and what family side)
HPN:________ DM: ________ Asthma: _________ TB: _________
Cardiac dse: _____ Cancer: ____ Allergies: _________

VII. OB GYNE HISTORY

Menarche: _________ LNMP: ______________

Cycle: __ regular __ irregular Duration: _____days
Quantity: # of pads/ napkins: ________ Fully/moderately/mild
Symptoms: __Dysmenorrhea __Spotting ___headache

Menopause: _______
Contraceptives: ____________________ Reason for stopping:__________________
____________________ Reason for stopping:__________________
____________________ Reason for stopping:__________________
 OB Score: G__ P __ ( ___________ )

VIII. REVIEW OF SYSTEMS

General ___weakness (___%) ___loss of appetite __low-grade fever __weight loss (___%)
___easy fatigability
Integument ___wound ___rashes ___erythema ___pallor ___clubbing of nails
___hyperpigmentation ___hypopigmentation ___mass
Head & Neck ___stiffness ___headache ___distension of veins ___mass ___dizziness
___swelling ___neck pain
Eyes ___pain ___itchiness ___redness ___corrective lenses (glasses/contact lenses/last exam)
___discharge ___ineteric sclera ___flashing light
Ears ___otalgia ___vertigo ___tinnitus ____difficulty hearing ___discharge ___hearing aid
Nose & Sinuses ___watery discharge/ itching ___epistaxis ___obstruction
Mouth & Throat ___toothache ___hoarseness ___dysphagia ___ulcers ___tongue fasciculation
___sore throat ___dentures ____
Respiratory ___cough ___dyspnea ___hemoptysis ___tachypnea ___pleuritic chest pain
___greenish phlegm
Cardiovascular ___angina ___dyspnea ___palpitations ____orthopnea __paroxysmal nocturnal dyspnea
GIT ___anorexia ___nausea ___vomiting ___diarrhea ___abdominal distention
___abdominal pain ___ constipation ___melena ___hematemesis ___hematochezia
___retching
GUT ___frequency ___nausea ___polyuria ___oliguria ___nocturia ___dysuria
___flank pains ___palpable mass
Vascular ___claudication ___ulcers
Hematologic ___easy bruising ___easy bleeding ___pallor
Endocrine ___polyuria ___polyphagia ___polydypsia ___diaphoresis ___heat/cold intolerance
MSS/ ___fractures ___joint pains ___edema
Extremities
Nervous ___seizures ___syncope ___tremors ____one-sded weakness ___slurring of speech
System ___headache
Autonomic ___fecal incontinence ___urinary incontinence
Deficiency

PHYSICAL EXAMINATION

GENERAL SURVEY

Development: ___poorly ___fairly ___well developed

Nutrition: ___poorly ___fairly ___well nourished
Mental status:
Consciousness: ___conscious ___comatose ___drowsy ___stuporous
Coherence: ___coherent ___incoherent
Oriented to: ___time ___place ___person
Cardio-respiratory distress:
___dyspneic ___tachypneic
___mild ___moderate ____severe
Orthopneic: ___no ___yes (difficulty of breathing when lying down) Relieved by: ____ no. of
pillows
Ambulation: ___bedridden ___weak but ambulatory ___ambulatory
Appears his/her chronological age: ___yes ___no

IV line: ___yes (left/right) ___no

Foley catheter: ___yes ___no
O2 via nasal cannula: ___yes ___no
NGT: ___yes ___no
Endotracheal tube: ___yes ___no
 Vital Signs: Anthropometric measurements
BP: _____________ mmHg, sitting/supine Weight: ___________kg
CR: _____________ beats/min, regular/irregular Height: ___________ cm
PR: _____________ beats/min, regular/irregular BMI: _________ kg/m2
RR: _____________ cycles/min Interpretation: ___________
Temp: ___________ C, axilla/oral/rectal

SKIN

A. General Characteristics:

I. Inspection
A. Color: ___pallor ___jaundice ___erythema ___normal (no pallor/jaundice/erythema)
B. Edema: ___yes ___ no (if yes, generalized/localized_______ location_________)

II. Palpation
A. Temperature ___febrile __cool to touch ___normal (not febrile nor cool to touch)
B. Turgor: ___ prompt return of skin (normal) ___ delayed return of skin (dehydration is present)
C. Degree of moisture: ___dry ___moist (if yes, generalized/localized_______ location_________)
___normal (no excessive dryness or moisture)
D. Hardness (sclerosity) or Laxity (nonresiliences)
__ normal skin: soft and resilient
__ sclerotic (like scarred tissue) eg. In scleroderma
__ non resilient eg. In cutis laxa

B. Presence or absence of skin lesions

I. Primary Lesions: __ no primary skin lesions __ macule __ patch __ papules __ plaques __

nodules __tumors __ vesicles __ bullae __ wheels __ pustules
1. Color?
a. Brown(melanin/postinflammatory/hemosiderin/stasis dermatitis)
b. yellow-orange(xanthoma/necrobiosis lipoidoca(DM)
c. yellow-green(bile)
d. yellow(lymph/bile/drugs (atrabine)
e. orange(carotene, myxedema/DM/hypopituitarism)
f. red/violaceous (purpura –extravasation of blood/erythema-vasodilation)
g. blue – ceruloderma (dermal melanin pigmentation-mongolian spots/ drugs/chemicals –Fe,
Pb,Ag,Au,Amiodarone, Minocycline/ cyanosis)
2. Shape or configuration? Round/annular,arciform,iris/targetoid,oval,linear,umbilicated,reticular/lacy
3. Distribution or location?
Extent of involvement: Flexural/extensor surfaces?sunexposed?areas of
contact?Isolated,scattered, grouped/clustered, dermatomal, widespread,
generalized, universal (entire skin, hair & nails)______ percentage
involved______
Pattern: symmetry (unilateral/bilateral), exposed areas, sites of pressure, intertrigenous areas

II. Secondary Lesions: __scales __crusts __erosions __ulcers __fissures __lichenification

__atrophy __sclerosis __scarring

C. Skin appendages (hairs and nails)

I. Hair:
1. Abnormalities in Amount: __hair loss (if yes,
distribution?patchy/diffuse,generalized/localized________) __hair excess
(hirsutism/hypertrichosis)
2. Structural Abnormalities: __ Nodules __Easy breakage
3. Color changes: white(vitiligo)/graying(young)/redbrown(malnutrition)/green(chlorinated water)/hair dyes
II. Nail Unit
__dystrophy or deformities (pits, longitudinal or transverse grooves, thickening)
__clubbing (cardiac/pulmonary d/o) __koilonychia(spoon-shaped –iron def anemia)
 __wedge-shaped nails (genetic disorders)
__color changes (disease/drugs/trauma/exogenous pigment or stain)
Good capillary refill: ___yes ___no __tenderness (paronychia)

D. Tongue __microglossia __macroglosia(amyloidosis, down’s syndrome, angioderma, hemangioma,etc.)

__color changes (white-premalignant leukoplakia, lichen planus/black-HIV infection)
__fissured tongue (genetic d/o) __smooth tongue (IDA) __furry tongue (hypertrophy or filiform papillae)

HEAD AND NECK

Hair: color: ______ density: _____ distribution: _____ texture:______ pattern of loss:______
Scalp: ___lumps ___scales ___flakes
Skull: ___normocephalic others _______
___symmetrical ___asymmetrical
___lumps Location: _______
___tenderness Location: _______
Facial Symmetry:
___symmetrical, if not, give location: ______
___deformities ___mass/swelling ___tenderness
Enlarged parotid/submandibular glands: ___yes ___no
Cervical lymphadenopathy: ___yes ___ no If yes, where in particular: _________
Trachea: ___midline ___deviated (left/right)
Thyroid palpable? ___yes ___no
Thyroid cartilage moves with deglutition: ___yes ___no

JVP (distance of the RA to the sternal angle): _____cms H20 (1 ruler vertical to the anlgle of Louis, 2nd ruler perpendicular place
at the level of the JVP. Measure in cm and add 5 cm)
Carotid pulsations: ___equal Carotid bruit: ___present __absent

EYES

Symmetrical: __yes __no

Color of conjunctiva: __pale __pink __red
Direct light reflex: __present __absent
Consensual light reflex: __present __absent
Pupil reactive to light? ___yes (size _____mm) __no
Cornea & lens opacities: __yes __no
Visual acuity: _____/_____

I. VISUAL ACUITY
A. Distant Vision: (Snellen’s chart)
Without With correction
EYES Pinhole With correction
correction & Pinhole
Right Eye

Left Eye

B. Near Vision: (Jaeger’s chart)

Without Correction With Correction
Right Eye
Left Eye

II. GROSS EXAMINATION (drawing of OU)

III. OCULAR MUSCLE MOVEMENT:

Normal
 IV. TONOMETRY: __soft __hard
(Measure the IOP. Ask the patient to look down, one eye at a time then palpate the upper eyelid with both of your index fingers via
bimanual technique. Never palpate if with perforation or ruptured for obvious reason)

V. FUNDOSCOPY:
Red-Orange Reflex Media Disc Cup Disc Ratio Arterio-venous ratio Hemorrhage Exudate Foveal reflex

OD
OS

EARS

Auricle/Preauricle: Mass: __yes __no

Lesions: __yes __no
Patent: __yes __no
Cerumen: __scanty __impacted others: _______
Tympanic Membrane: __pearly gray __pink __shiny __translucent __intact
__perforated
__lesion __mass __discharge
Tuning Fork Tests:
Weber: __midline __left __right
Rinne: __ (+) AC > BC __ (-) AC < BC
Schwabach: __equal __prolonged __shortened

NOSE

Symmetrical: ___yes ___no

Inferior turbinate & anterior septum: color_________
Masses: ___yes Describe: __________ ___no
Lesions: ___yes Describe: __________ ___no
Patent (via breath test): ___yes ___no
Septal deviation: ___midline ___left ___right

MOUTH AND THROAT

Lips: Symmetry: ___yes ___no

Mass: ___yes ___no
Ulceration: ___yes ___no
Oral mucosa & gums: Color: ___pinkish ___reddish others: _____
Teeth: ___complete ___incomplete ___absent ___false teeth
___plaque ___stains ___carries
Tongue: ___midline ___deviated to right ___deviated to left
Color: ________ ___mass ___ulceration
Wharton’s duct patent? ___yes ___no
Stensen’s duct patent? ___yes ___no
Uvula & palate, symmetric rise? ____yes ____no (Have the patient say "AHH")

CHEST AND LUNGS

Inspection:
Symmetrical chest: __yes __no
Deformities: __pectus excavatum __pectus carinatum __kyphosis __scoliosis
Masses/abnormal bulging: __yes, location:_____ __no
Chest expansion: ___symmetrical ___local lagging
Use of accessory muscle:__yes ___no
AP:transverse diameter: ________
Assoc. extra-pulmonary findings: __clubbing __facial puffiness __prominent veins (anterior chest wall)

Palpation:
Cervical lymph nodes: __present __absent
Tenderness: __yes, location:_________ __no
Respiratory excursion (place both thumb at the level of 10th rib and ask to inhale/exhale): +/-: ____
Tactile fremitus: __equal ___increased (left/right) __decreased (left/right)
 Percussion:
__ hyperresonant (if yes, in what areas?___________________)
__ resonant (if yes, in what areas?___________________)
__ dull (if yes, in what areas?___________________)

Relative Relative
Relative pitch location Examples
intensity duration
Flatness Soft high Short Thigh Pleural effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
Resonance Loud Low Long Normal lung Chronic bronchitis
Emphysema,
Hyperresonance Very loud Lower longer None
pneumothorax
Gastric air Large
tympany loud High
bubble pneumothorax

Auscultation (lean forward then cross his arms at the anterior chest and breath through his mouth) :
___ Normal breath sounds:
___Bronchial
___Vesicular
___Bronchovesicular
___Tracheal

Intensity of Pitch of
Location where normally
Breath sound Duration of sounds expiratory expiratory
heard
sounds sound
Inspiratory sounds last longer
Vesicular Soft Relatively low Over most of the lungs
than expiratory ones
st nd
Commonly in the 1 and 2
Inspiratory and expiratory
Bronchovesicular Intermediate Intermediate ICS anteriorly and between
sounds are about equal
the scapulae
Expiratory sounds last longer Over the manubrium, if heard
Bronchial Loud Relatively high
than inspiratory ones. at all
Inspiratory and expiratory
Tracheal Very loud Relatively high Over the trachea in the neck
sounds are about equal.

__ adventitious sounds sounds:

___crackles (Short (less than 12-15 msec), discontinuous, explosive sound, primarily an inspiratory
sound)
___wheezing (Continuous sound of musical quality, high-pitched, primarily expiratory)
___rhonchi (Low-pitched, snoring quality, continuous, early expiratory)
___stridor (High-pitched, continuous, purely inspiratory, similar to wheezing except that its inspiratory)
__ decreased breath sounds (left/right)

CARDIOVASCULAR

Inspection
Precordial bulgge: ___present __absent
Point of Maximal Impulse: ___________________ (area of the cardiac surface that maximally pulsates)
(Normally at or medial to the left midclavicular line in the 5th or possibly the 4th ICS)

Palpation
Apex Beat:
Heaves: ___present ___absent (If present, location? ________)
Thrills (a palpable murmur): ___present ___absent (If present, location? ________)

Percussion
Heart span: _____ ICS to _____ ICS (cardiac area of dullness from the point of reference (midsternal line)

Auscultation
Rate: ___Normal (60-100bpm) ___Bradycardia (<60bpm) ___Tachycardic (>100bpm)
Rhythm: ___regular ___irregular (report regularly irregular or irregularly irregular)
Heart sounds: S1 > S2: ___base __apex S2 > S1: ___base__apex
Presence of S3 and S4: ________
Murmurs: ___yes ___no
Intensity (grading):____
Timing: ___________
Character: ___blowing ___harsh ___rumbling ___ejection ___continuous
Location: _________
ABDOMEN

Inspection
Contour: __scaphoid __flat __globular
Symmetry: __symmetrical __asymmetrically enlarged (identify quadrants: ________)
Lesions
Scars: __yes __no (if yes, location:________, shape:________, length:________)
___ Discoloration ___Visible mass ___Visible peristalsis ___Visible pulsations
Umbilicus: ___inverted ___everted

Auscultation
(Best appreciated at or just below the area of the RLQ but generally all over the abdomen)
Bowel sounds: _____/min
___normal (low pitched, 5-30 bowel sounds/min
__hypoactive (4 or less) __hyperactive (>30 or + bowel sounds every 2 seconds)

Palpation
Tenderness: __yes __no __direct __rebound (If yes, what quadrants? ______)
Kidneys: __Palpable (Left/Right) ___Not palpable
Liver (RUQ Palpation): __Palpable __Not palpable
Liver (Hooking Technique): __Palpable __Not palpable
Spleen: __Palpable __Not palpable
Aorta: __Palpable __Not palpable

Percussion
Liver span: ___cm along the right midclavicular line (normal: 8-12cms)
Abdominal quadrants: ________ (normally, tympanitic all over)
Traube's space: ___resonant (intact) ___dull (obliterated)

Special Maneuvers:
___ Fluid wave ___Shifting dullness ___Succussion splash
___ Murphy’s sign ___Rovsing’s sign ___Psoas sign __Obturator sign
___ Kidney punch/Costovertebral angle tenderness (Left/right)

EXTREMITIES

Do you have any pains in your joints? ___yes ___no

Can you dress yourself without difficulty? ___yes ___no
Can you walk without difficulty? ___yes ___no

Axial Skeleton:
TMJ: ___redness ___mass ___swelling ___deformity ___tenderness ___crepitus
__limitation of motion
Spine: __cervical &lumbar lordosis __thoracic kyphosis __lateral deviation ___redness
___mass ___swelling ___tenderness ___limitation of motion of the cervical & lumbar
spines
Sacroiliac Joint: ___redness ___swelling ___tenderness

Upper Extremities:
Tinel's Test: ___________ Phalen's Test: _________
Finkelstein's test: _______ Arm circumference: _____

Lower Extremities
Test for knee stability: Anterior drawer test: __________ Posterior drawer test: _________
Valgus & Vargus test: _________ Mc Murray Test: _____________
Thigh circumference: ______
True leg length: _____
Apparent Leg Length: ____

NEUROLOGIC EXAM

Mental Status:
General behavior: ___normal ___immobile ___hyperactive ___slovenly dressed ___agitated
___quiet ___neat ___dressed appropriately according to age and occasion

Stream of talk: ___normal ___rapid ___slow ___scarce ___verbose

Mood: ___appropriate ___labile ___silent ___euphoric ___hostile ___agitated

 Content of Thoughts: ___illusions ___delusions ___paranoia ____misinterpretation
____hyperchondriasis ___auditory/visual hallucination

Intellectual Capacity: ___bright ___average ___dull ___demented ___retarded

Sensorium:
Consciousness: ____awake ____drowsy ____obtunded ___delirious ___stupor
___coma
Attention Span: ____normal ___short
Orientation: ____normal ____disoriented

Memory
Remote: ____good ____poor ____fair
Recent: ____good ____poor ____fair
Immediate: ____good _____poor ____fair
Fund of Information: ____well-informed ____uninformed
Calculation: ____able ___dyscalculia

Insight/Judgment _____________________

Cranial Nerves:
I: able to smell: ____yes ____no II, III, IV, VI: (already assessed)
V: good masseter and temporalis tone, V1, V2 and V3 equal facial sensation: ____yes ___no
VII: facial symmetry: ___yes ___no can taste on the anterior 2/3 of tounge: ___yes ___no
IX, X: swallow: ____yes ___no, cough: ____yes ___no gag reflex: ____(+) ____(-)
XI: good trapezius tone: ___yes ____no good SCM tone: ___yes ____no
XII: tongue midline: ___yes ___no fasciculations: ___yes ___no

Sensory

Touch: ___intact ___not intact

Pain: ____intact ___not intact
Vibratory sense: ____intact ___not intact
Position sense: _____intact ___not intact
Romberg: ____intact ___not intact

Motor
Inspection:
Posture/Gait:_______________
Somatotype:________________
General Activity:_____________
Tremors (distribution type):______________
Involuntary Movements:________________

Palpation:
Muscle bulk: ___atrophy ___hypertrophy ___normal bulk
Body symmetry:
Joint malalignments:
Fasciculations:
Muscle tone: ___flaccid ___spastic ___rigid ___normal

Manual Muscle Strength Testing:

 Reflexes

Deep Tendon Reflexes:

___biceps ___triceps ___patellar ___brachioradialis ___Achilles tendon
Physiologic Reflexes: ___anal wink ___abdominal reflex ___jaw jerk
Pathologic Reflexes:
___Babinski (left/right) ___ankle clonus (left/right) ___snout ___grasp reflex ___palmomental

Cerebellar
Nystagmus: ____(+) ____(-)
Tandem Walk: _____(+) _____(-)
Dysmetria: Finger to nose: _____(+) ____(-) Heel to shin: _______(+) ____(-)
Dysdiadokinesia: _______(+) ____(-)
Tandem gait: ______(+) _____(-)
Rebound phenomenon: ______(+) ____(-)

Meningeals
Passive Neck Flexion: ____(+) ____(-)
Kernig’s: ____(+) _____(-) (a positive response is sudden flexion of the knee)
Brudzinski: ____(+)_____(-) (observe for a response- neck flexion)

Higher Cerebral Functions

Aphasia
Expressive (of spoken language): ____(+) ____(-) (name 10 fruits, objects)
Expressive (of written language): ____(+) ____(-) (writing complete sentence, spelling)
Word repetition: ____(+) _____(-) (wala nang pero-pero pa) (no-ifs-and-or buts)

Apraxia
Ideomotor Apraxia: ____(+) ____(-) (gives direction or requests patient to do a voluntary movement: light a candle)
Dressing Apraxia: ____(+) ____(-) (asks patient to put on hospital gown or jacket)
Constructional Apraxia: ____(+) ____(-) (asks patient to draw any shape ex clock drawing test)
Gait Apraxia: ____(+) ____(-) (asks patient to walk)

Agnosia:
Astereognosia: ____(+) ____(-) (asks patient to identify objects by palpating its texture & form in his hand)
Agraphognosia: ____(+) ____(-) (asks patient to identify numbers drawn by examiner on his palm)
Finger Agnosia: ____(+) ____(-) (asks patient to identify examiner's fingers)
R-L Disorientation: ____(+)____(-) (asks patient to identify right and left side of body)

---------------------------------------------------------------------------------------------------------------------------------------------------

PRIMARY IMPRESSION: __________________________

BASES:
I. Clinical History
II. PE
PLAN
CURRENT HEALTH STATUS: ______________________
 FAMILY REPORT

Surname_________, October 2017

I. FAMILY CLASSIFICATION

1. Structure 2. Location 3. Family Stage

 Nuclear  Matrilocal  Unattached young adult
 Extended  Patrilocal  Newly married couple
 Communal  Neolocal  Family with young children
 single parent  Family with adolescents
 blended(stepmomdad)  Launching family
 Family in later years
4. Decision- Making 5. Set –Up 6. Class
 Matriarchal  Democratic  Lower
 Patriarchal  Authoritarian  Middle
 Equalitarian  high Class

II. FAMILY LIFELINE (Marriage of patient/children’s marriage, Death, Birthdays, Confinement/hospitalizations,

graduation, work, migrated/transfer of house, education – start of primary educ., courtship to marriage)

YEAR PSYCHOSOCIAL EVENT MEDICAL EVENT IMPACT

III. FAMILY GENOGRAM (at least 3 generations) then explain. Suggested Legend:

II

III

IV
IV. FAMILY PROFILE (immediate family members/kasama sa bahay)

A. Sociodemographic profile

CIVIL INCO RELI REL TO

NAME AGE SEX EDUC.ATT. OCCUP
STATUS ME G INDEX

B. Economic Profile

Financial provider: __________________ Work_____________ Wage:___________/month.

Relationship to the index: ________________
The rest of the family members

NAME REL TO INDEX WORK WAGES

Estimated monthly expense of the family:______________ Is it adequate for the family? ______________
Saving money for medical emergencies? Y/N?
House: rented/owned?
Business: ___________________ Earned amount/month: __________

Breakdown of expenses: (by percentage in a pie graph. Example ->)

Electricity ____ Telecommunication _____ Food _____
Water ______ School expenses ________
Others: (enumerate) _________________________________________
 C. Environmental Profile (Discuss the factors that probably increase the risk for disease occurrence)
Number of family members: ___ Currrently lives with: _________________
House
One storey: _______ Concrete/Wood: _____
Address: _______________
Drainage: ____ Pets: ______
Location (near of what establishment) ___________
Toilet: (with flush/de buhos): ____________ Water source: _______
Water Storage: ________ Drinking water: ____________ Electricity: ______________
LPG for cooking: Y/N: _____ Garbage Collection: Frequency?_________ Day? ________

V. PSYCHODYNAMICS

Closest family member:________. Why? ____________________________________

Good relationship with the rest of the family members: _____________________________
Conflicts in the family: ___________________________________________________

NAME REL TO INDEX TYPE OF REL (Good/Bad) REASON

VI. FAMILY FUNCTION

A. FAMILY MAP (Patient) then interpret the drawing. Legend: = strong bond/overinvolved relationship
Example:

B1. APGAR 1
Paminsan Halos
APGAR QUESTIONNAIRE Palagi (2)
Minsan (1) Hindi (0)
“Ako’y nasisiyahan dahil nakakaasa akong tulong sa aking pamilya
Adaptation
sa oras ng mga problema.”
Ako’y nasisiyahan sa paraangnakikipagtalakayan sa akin ang
Partnership
aking pamilya tungkol sa aking mga suliranin.”
“Ako’y nasisiyahan na ang akingpamilya ay tinatanggap at
Growth sinusuportahan ang aking mga naisgawain patungo sa mga
bagong landas para sa aking ikauunlad.”
“Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya ang
Affection kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit, lungkot at pag-ibig.”
“Ako’y nasisiyahan na ang aking pamilya at ako ay nagkakaroon
Resolve
ng panahon para isa’t-sa.”
Highly functional = 8-10; Moderately functional = 4-7; Severely dysfunctional = 0-3
APGAR I. EXPLAINED BY THE INDEX PATIENT

Adaptation- Why? Help from family members? Site an example.

Partnership- Why? How do you communicate with your problems?

Growth- why? Site examples of decisions that were supported by your family.

Affection- why? How does your family express anger, love, sorrow?

Resolve- why? How do you celebrate special occasions such as Xmas, Birthdays, or New years?

B2. APGAR II
NAME AGE SEX REL QUALITY OF RELATIONSHIP

Well/Fairly/Poor. HOW/WHY?
 C. SCREEM
HELPFUL IN
SCREEM RESOURCE PATHOLOGY/WEAKNESS TERMS OF
HEALTH (Y/N)
Member of an organization? Loves to stay alone? Is Social Aspect
Describe the relationship with friends? Doesn’t want to talk to people? Helpful in your life?
Neighbors? Officemates? Co-members of How do they see people around In what way?
organization? them? Socially isolated?
Can tell problems? Or
No pathology/weakness seen

Social

Respectful? Po or opo? Perspective in terms of

Uses herbal medicines? prescribed medications
Goes to albularyo? compared to herbal medicine
Do you believe in superstition?Karma as it (which is better?)
affects health?

Cultural

Religion? Goes to church every Sunday? Blood transfusion?

Prays every day? Religious activities? Don’ts under their religion
Insights about God? Do you question God why you
If with problems how do they handle it had the disease? Do you think
religiously? it’s a punishment?

Religious
 Financial difficulties? Example:
In case of Emergency, where/whom to turn to? The family has financial
difficulties especially in times of
medical emergencies.
Is it practical to seek consult with
minor illness? Why?

Economic

Educ attainment: Public information about the

Can understand her illness: Causes, proper usage of antibiotics and
Precipitating factors the dangers of misusing them
Insights about his/her illness/medications: are lacking.

Education

Minor illness: Knowledge of the roles of

Medication where? ____________ primary, secondary and tertiary
Consultation done in:________________ hospitals.
Knows what type specialty to go
Major illness: to for consultation?
Medication where? _________________ Generic vs Branded medicines?
Done in______________________ Perspective.
Emergency where? Understanding about their
With nearby clinics? Health centers? illness. DIscuss
Aware of health programs of the community?

Medical
VII. INDIVIDUAL REACTION TO ILLNESS
1. How does the index patient feel about his/her illness (hopeful/Angry/depressed/worried, etc)? Why?
2. How do the family members feel about the illness (worried/hopeful/depressed/angry)? What do you think is/are the
reason/s of that feeling? Especially the partner? Is she/he supportive/Fearful? How can you say?
3. Insights about her/his illness?

VIII. ASSESSMENT OF IMPACT OF ILLNESS

1. Changes in the roles and responsibilities in the family?_____________________________________
2. Does the px thinks that her illness would cause financial problems? How or what are the possible
effects?__________________
3. Stage of Family Illness Trajectory and Discuss the basis:
• 1: onset of illness
• 2: impact phase (rx to the dx)
• 3: therapeutic efforts
• 4: early adjustment to outcome recovery- coping mechanism, return to health
• 5: adjustment to permanency of outcome- point to family’s adjustment to crisis
4. Are there any other medical conditions in the family (e.g. HPN mother/father, DM Brother)

IX. IDENTIFIED PROBLEMS AND RECOMMENDATION (Do this at home)