U.N.

Avenue corner Taft Avenue, Ermita, Manila

Medical Director’s Office
HISTORY AND PHYSICAL EXAMINATION
Tel. No. 523-81-31 to 64

Date (mm/dd/yyyy): / / Time: : PM AM Patient ID No.:

Patient’s Name: Surname Given Name Middle Name Gender
Male Female
Attending Physician: Religion Birth Date (mm/dd/yyyy) Age
Dr. Roman Catholic INC Islam Others: / / years old months old

Chief Complaint: Pre-Admission Meds:

History of Present Illness:

Past Medical History:

Allergy
HPN x years, Highest BP , Usual BP
DM x years, Complications:
Asthma , Since Last attack:
PTB, Treatment:
Thyroid disorder:
Cancer:
Stroke Myocardial Infarction
Congestive Heart Failure CKD, stage
Others:
Surgical History
Year Operation Done Indication/Histopathologic Diagnosis Institution

Personal and Social Other relevant Hx:

Smoker, sticks per day for years, stopped Ob-Gyne History:
Alcohol Drinker, M I D A S G P ( - - - )
Illicit drug use, LPM PMP Menopause y/o
Travel history, Family Planning Method:
Past Pregnancy:

Family History:
HPN DM Stroke
Thyroid Asthma PTB
Cancer: Others:

Review of Systems
General: Fever Chills Fatigue Malaise Night Sweats weight loss kg weight gain kg
Skin / Appendages: Rash Itch Pigmentation Texture change of skin Excessive sweating Abnormal nails Acne Hair growth
HEENT: Visual Acuity Blurring of vision Diplopia Photophobia Eye pain Glaucoma Trauma Hearing loss Ear pain
Discharge
Tinnitus Vertigo Sense of smell Colds Obstruction Epistaxis Postnasal discharge Sinus pain Hoarseness Change in
voice
Sore Throat Bleeding gums Swelling gums Tooth Decay Tooth Extraction Ulcers Disturbance of taste Lymphadenopathy Tender
nodes
Neurologic: Dizziness Headache Seizure Paralysis Slurred speech Decrease responsiveness
Cardiovascular: SOB Chest pain HPN Syncope Cyanosis
Pulmonary: SOB Tachypnea Dyspnea Chronic cough Wheezing
Gastrointestinal: Appetite nausea Vomiting Diarrhea Constipation Anorexia Reflux Chewing difficulties Swallowing difficulties
Genitourinary: Frequency Control Polyuria Eneuresis Dysuria Hematuria
Musculoskeletal: Joint pain Swelling Malaise Spasm Fracture Amputation
Cognition/Perception: Senses language writing memory concentration Orientation Judgement
Psychological: Mood Affect Behaviour Psychological disturbances
Others (specify):

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