PATIENT’S PROFILE

Date and Time:

Name: Sex: Civil Status: Religion: Race:
Residence: Occupation: Educational Attainment:
Date of Admission: Date of Birth: Age:
Source of Data: Percentage Reliability:

HISTORY OF PRESENT ILLNESS (HPI):

Chief Complaint (Unsa ang rason nga nagpa-admit?):

Characteristic (Unsa man ang sakit? Ga tusok-tusok? Huot? Gikumot?):

Location and radiation (Asa dapit? Diha ra nabati or apil pa ang lain nga part sa lawas?):

Onset/Duration: when it first began, sudden/gradual, continuous/intermittent (Kanus-a nagsugod? Unsa ka

dugaya? Gapadayon or putol-putol? Kalit lang or hinayhinay? Nagka grabe ang sakit or nagkawala?):

Setting (Under what circumstances does it take place) (Unsa man imong gibuhat usa ni sakit? Or kada
kanus-a man mu sakit?):

Symptoms associated (Unsay lain nga symptomas nga nabati?):

Severity/Quantity: pain scale, how it affects daily activity, wakes him up at night (Unsa ka sakit? 1-10?
Unsay epekto sa adlaw-adlaw nga buluhaton? Kung matulog, pukawon ba ka sa kasakit?):

Exacerbating factors (Unsa may makapa grabe?):

Relieving factors (Unsa may makapa alebyo?):

Past experience with symptom(s) (Nakasulay na ug bati aning mga symptomas sauna?)

a. Prior treatment? Response? Data from past charts? (Unsa may gi tambal or gihimo? Naayo ba?)

b. What has patient done about the symptom(s)

PAST MEDICAL HISTORY
Illness/ Surgeries/ Injury/ Toxins or Industrial Exposure/ Trauma/ Childhood Dse

Age Date Description/Dx/Mgt (note blood Hospital/Clinic

transfusion)
Chickenpox/
Hangga

Measles/
Tipdas

Mumps/
Bayook

Dengue

Malaria

Typhoid/Tipus

Polio

Tetanus

TB

Hepatitis

Hypertension

Diabetes

Cancer

Asthma/Hubak

Surgery/Operahan/
Tahi/Aksidente

Blood Transfusion/
Naabonohan

Others
Immunizations
Type Age Type Age
Diphtheria Hepatitis
Pertussis Mumps
Tetanus Measles
Rubella Influenza
Polio Others

FAMILY HISTORY (If present x if cause of death (indicate age and year of death)

Father’s side Mother’s side

Grandparents
Father
Mother
Siblings
Children
Others

PERSONAL/SOCIAL HISTORY
Marital Status: Name of Spouse: Age of Spouse:
Children: Age: : : : : : : : :
Sex: : : : : : : : :
Household composition/Living Situation (Kinsa ang kuyog sa panimalay?):
Housing:
Sources of social support (Asa/Kinsa gikan ang supporta? Financial? Emotional?):
Sources of stress (Kinsa or unsa gikan ang stress or kaguol?):
Coping styles (Unsa ang ginahimo kung maguol or ma stress para mahuwasan?):
Hobbies/Leisure activities (Unsa ang kalingawan?):
Religious affiliations and beliefs (Relihiyon?):
Activities of Daily Living (especially for elderly) (Unsay ginahimo/buluhaton adlaw-adlaw?):
Exercise:
Sleep:
Diet (Unsa ang ginakaon?):
Dietary supplements/restrictions (Gi inom nga tambal/maintenance or mga gi bawal? Drug
reactions/allergies):

Coffee, tea, caffeinated (tig-inom ug kape/ tsa):

Safety measures:
Alternative health care practices (Unsay lain ginahimo para sa panglawas?):

Smoking habit: age started: _______quit:______ type:_________ sticks/packs per day:____

Alcohol Use: quantity__________ frequency:_________ type:_______
Illicit Substance use (Tig gamit ug droga/marijuana):

OBSTETRIC/MENSTRUAL HISTORY
Menarche (Sugod sa dugo): Menopause:
Menstrual Flow Interval (Kada ika pila ka adlaw dug-on?):
Duration (Unsa ka dugay): Amount (Unsa ka daghan):
LMP (Kanus-a last gidugo?):
( ) Vaginal Discharge ( ) AbN bleeding ( ) Mammogram ( ) Others:
( ) Pelvic Pain ( ) History of STI ( ) Pap Smear
OB History: G: P: A: L:
Pregnancies:
Full Term: Postmature:
Premature: Abortions:

Sexual History
( ) Impotence ( ) Difficulties ( ) Others

Breasts
( ) Masses (Bukol) ( ) Pain ( ) Others
( ) Discharge ( ) Trauma

REVIEW OF SYSTEMS
General
( ) Recent weight change (Pagbag-o sa timbang) ( ) Overall weakness (Kaluya) ( ) Fever, Chills and
Sweats ( ) Sleep disturbance ( ) Fatigue/ Malaise (Gil-as/Kabudalay)
( ) clothing that fits more tightly or loosely than before

Skin
( ) Itching (katol-katol) ( ) Moles (alom) ( ) Skin Color change ( ) Lumps (bukol) ()
Rash ( ) Pigmentation ( ) Vasomotor changes ( ) dryness ()
Photosensitivity ( ) Hair ( ) Nails

Head and Neck

( ) Headache ( ) Neck stiffness ( ) lightheadedness (gaan ang ulo) ( ) Dizziness(lipong)
( ) Swollen glands ( ) goiter ( ) lumps

Eyes
( ) Spots in visual fields ( ) Flashing lights ( ) Transient vision loss
( ) Double/blurred vision ( ) Blind spot ( ) Red, Painful eyes
( ) Itching and tearing ( ) glasses/contact lenses ( ) Cataract/ Glaucoma

Ears, Nose, Sinuses, Mouth, Throat

( ) Sore throat ( ) Frequent colds ( ) nasal stuffiness ( ) nasal discharges ()
nose bleed ( ) sinus trouble ( ) bleeding gums ( ) dentures ()
last dental exam ( ) dry mouth ( ) sore tongue ( ) hoarseness
( )hearing ( ) tinnitus ( ) vertigo ( ) earaches
( ) hearing aids

Respiratory
( ) Cough ( ) hemoptysis ( ) pleurisy
( ) SOB ( ) Sputum (color,quantity) ( ) wheezing (kutas)
( ) chest tightness ( ) asthma ( ) pneumonia
( ) bronchitis ( ) emphysema ( ) exercise intolerance

Cardiovascular
( ) heart trouble ( ) palpitations ( ) edema
( ) high blood pressure ( ) dyspnea (w/ or w/ exertion) ( ) ECG tests
( ) rheumatic fever ( ) orthopnea ( ) CV tests
( ) chest pain/discomfort ( ) paroxysmal nocturnal dyspnea
Gastrointestinal
( ) dysphagia
( ) indigestion/heartburn
( ) appetite/weight loss
( ) nausea,vomiting,hematemesis
( ) excessive belching/flatulence
( ) bowel movements ( ) rectal bleeding
( ) stool color/size ( ) constipation/diarrhea
( ) change in bowel habits ( ) abdominal pain
( ) pain with defecation ( ) food intolerance
( ) jaundice ( ) hepatitis

Peripheral Vascular
( ) intermittent claudication ( ) leg cramps ( ) varicose veins
( ) swelling with tenderness/redness ( ) change in fingertips/toes

Urinary
( ) frequency of urination ( ) polyuria/oliguria ( ) nocturia
( ) urgency ( ) dysuria (onset) ( ) flank pain
( ) hematuria ( ) kidney stone ( ) suprapubic pain ()
incontinence ( ) hesitancy /dribbling
Genital
( ) hernia ( ) discharge/sores ( ) sexual habits
( ) birth control ( ) condom use ( ) age of menarche
( ) regularity ( ) duration ( ) amount
( ) bleeding during intercourse ( ) LMP ( ) itching and abnormal discharge

Musculoskeletal
( ) Joint stiffness ( ) Low back pain ( ) Muscle pain ()
Cramps ( ) Weakness ( ) Difficulty moving or walking
( ) Able to climb up and down stairs ( ) Trauma ( ) Swelling ( ) Restriction of movement/fx

Endocrine
( ) Thyroid trouble ( ) Salt cravings ( ) hirsutism/alopecia
( ) Heat/cold intolerance ( ) Excessive thirst/hunger ( ) quality of hair
( ) Loss of sexual drive ( ) Excessive sweating

Hematopoietic
( ) Abnormal bleeding ( ) Pica ( ) Easy Bruising ()
Frequent infection ( ) Anemia ( ) Swelling/Lumps/Bumps
Neurologic
( ) Fainting or passing out
( ) Seizures
( ) Weakness on one or both
sides of the body
( ) Loss of sensation (numbness) ( ) Memory disorder
( ) tingling (“pins and needles”) ( ) Headaches
( ) Dizziness ( ) Blackouts
( ) Loss of balance/Lack of coordination ( ) Tremors

Psychiatric
( ) Nervousness/Anxiety ( ) Intrusive thoughts ( ) Auditory hallucinations
( ) Depression ( ) Loss of good judgment or insight
( ) Mania ( ) Visual hallucinations