Republic of the Philippines

Department of Education
Region XI
Schools Division of the Island Garden City of Samal

MEDICAL HISTORY REPORT FORM

I. Personal Details
Name of Patient: _Age:_ Sex: _
Birthdate: _ Birthplace: _ Religion: _
Marital Status: Contact No.: E-mail Address: _ _
Address ___
Position: _ Office: _________ Superior:
Emergency Contact (Name, Contact, Relationship) __________________________
 Underweight < 18.5
 Normal 18.5-22.9
II. Physical Examination  Overweight 23-24.9
 Obese I 25-29.9
Weight: Height: _ BMI: _ Category: _____ __
 O bes e II > 3 0

BP: PR: RR: __ _ Temp: _ _

III. Past Medical History
• Medical:
 Diabetes  Cancer:
 Hypertension  Blood transfusion
 Bronchial asthma  Others: _
 Allergies: _
• Allergies: ______________________________________
• Surgeries: ______________________________________________________________
• Hospital admissions ______________________________________________________
• Screening tests:
 X-ray, Chest:  Breast USD or mammogram:
 Pap smear:  Others: _
 Digital rectal examination
• Obstetric and Gynecologic History
o Obstetric Score: G P ( ____ )
o Type of Deliveries: Complications during delivery: _
o Last Menstrual Period: Cycle: No. of pads per day: _
o Menarche: _ years old Dysmenorrhea?
• Vaccination History:
(Check the type of vaccine received and note the number of doses and year -2x, 2022)
Childhood Immunizations: Adult vaccinations:
Hepatitis B: _ Influenza/Flu:
Pneumococcal: _ Pneumococcal:
Diptheria, Pertussis, Tetanus (DPT): _ Tetanus Toxoid:
Measles, Mumps, Rubella: Antirabies:
BCG:_ COVID vaccine:
Others: Others: _
• Medication History (Drug Name, Dose, Frequency: eg. Amlodipine 10mg/tab, once daily):
Maintenance Medications:
Vitamin and Herbal Supplements:
Others:
IV. Family History
 Heredofamilial Diseases  Kidney disease: _
 Diabetes  Mental disorders:
 Cerebrovascular Accident/Stroke  Cancers:
 Heart Disease  Genetically transmitted diseases(Down’s syndrome,
 Hypertension/High Blood Pressure Thalasemmia, etc.)
 Atopic Disorders  Infections: _
 Bronchial Asthma  Others:
 Allergic diseases:  With family member who died of heart disease before
 Goiter or Thyroid disease: 50 years old
 Liver disorders:
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 V. Personal-Social History
1. Substance Use
1. Cigarette: pack-year/s (Sticks per day/20) x years
• No. of sticks per day:
• Year started smoking:
• If stopped, please indicate year: _
• CAGE questionnaire:
 Have you ever felt you needed to Cut down on your drinking?
 Have people Annoyed you by criticizing your drinking?
 Have you ever felt Guilty about drinking?
 Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your
nerves or to get rid of a hangover?
2. Alcohol
• No. of times/drinking sessions per week:
• No. of standard drink consumed per drinking session:
1 standard drink =
350 ml of regular beer (5% Alcohol)
147 ml of wine (12%)
44 ml of 80-proof spirits (40%)
• Type of alcoholic drink consumed:
3. Other illicit substances:
2. Diet and Exercise:
VI. Review of Systems
General:  shortness of breath,  Painful intercourse
 recent weight change  pain with a deep breathing Musculoskeletal:
 weakness Cardiovascular:  Muscle or joint pain or
 fatigue  chest pain or discomfort stiffness
 fever  palpitations.  Swelling or redness
Skin:  need to use pillows at night to weakness, or limitation of
 Rashes, lumps, sores ease breathing motion or activity
 itching, dryness  swelling in the hands, ankles, Psychiatric:
 changes in hair or nails or feet
 changes in size or color  Nervousness
 Intermittent leg pain with  depression
of moles exertion  suicidal ideation: in the past
Head, Eyes, Ears, Nose, Throat  varicose veins; past clots in
(HEENT): few weeks, have you
the veins
 Headache  wished you were dead?
Gastrointestinal:
 dizziness  difficulty or pain during  felt that you or your
 lightheadedness swallowing family would be better off
 glasses or contact lenses  heartburn if you were dead?
 eye pain or redness  changes in appetite  have you been having
 blurred vision, spots, specks,  change in bowel habits thoughts about killing
flashing lights, yourself?
 rectal bleeding or black or
 changes in hearing  ever tried to kill yourself?
tarry stools
 tinnitus or ringing in the ear Neurologic:
 earaches, infection, discharge  hemorrhoids
 Abdominal pain  Changes in attention, speech
 hearing aids
Urinary: or memory
 nasal stuffiness or discharge
 urination >3x at night  Paralysis
or nosebleeds
 bleeding gums  burning or pain during  numbness or tingling
 dentures urination sensations
 dry mouth or sore throats  blood in the urine tremors or seizures
 hoarseness (hematuria), urinary infections Hematologic:
 goiter, lumps, pain, or  flank pain  Anemia or paleness
stiffness in the neck  easy bruising or bleeding
Breast: Genital: Endocrine:
 Lumps, pain, or discomfort  Hernias  heat or cold intolerance
 nipple discharge  discharge from or sores on  excessive sweating,
Respiratory: the penis or vagina  excessive thirst or hunger
 Cough  testicular pain or masses

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VI. Laboratories:
 CBC-PC:
 CXR-PA:
 Urinalysis:
 Blood chemistry:
 FBS _  Crea _
 SGPT _ _  BUN
 SUA  CHO
 Others _________________________________________

VII. Impression:

VIII. Treatment and Medications:

IX. Recommendations:
 CLASS A - Physically fit for any work
 CLASS B - Physically under-developed or with correctible defects, (error of refraction dental caries, defective
hearing, and other similar defects) but otherwise fit to work.
 CLASS C - Employable but owing to certain impairments or conditions, (heart disease, hypertension, anatomical
defects) requires special placement or limited duty in a specified or selected assignment requiring follow-up
treatment/ periodic evaluation.
 CLASS D - Unfit or unsafe for any type of employment (active PTB, advanced heart disease with threatened
failure, malignant hypertension, and other similar illnesses).

Notes:
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Licensed Government Physician

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 DENTAL HISTORY REPORT FORM
Pertinent Medical History Dental History
 Hospitalized within the past 5 years?  Is this your first dental visit?
o What was the diagnosis?  Have you any of your teeth extracted?
_ _ _ _ __ ___  Are you wearing any dental appliance (eg.dentures,
 Under the care of a medical doctor? braces)?
 Do you have any bleeding tendencies? o What type? __ _ ____ _ __
 Are you on a special diet? o How many? __ _ __ _ _____
 Were told that you have cancer or tumor?  Do you have any discomfort at this time?
_ _ _ _ __  Are you comfortable with dental treatment?
For Women  When was the last time you visited a dentist?
 Are you pregnant? o Date of last treatment: __ _ _ _ _ __
 Are you on birth control pills? o Type of treatment: _ _ ___ _ _ _ _
 Do you anticipate becoming pregnant?

Chief complaint: _

History of Present Illness

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Dental Chart

Treatment Plan
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Licensed Government Dentist