HISTORY AND PHYSICAL EXAMINATION

Date of Interview: _______________________________________

Time of History: _________________________________________
Informant: _______________________________________________
Relationship to the Patient: ____________________________
% Reliability: ____________________________________________
Source of Referral ______________________________________
I.
GENERAL DATA
Patients Name: __________
Age: __ ___ Sex: ___ __
Marital Status: ________________
Address: _________________
Birthday: ________
Birthplace: ____________
Nationality: ______
Religion: _____________
Occupation: ______
Date of Admission/Consultation: ___________________________
Time of Admission/Consultation: _______
No. of times admitted:
_
II.
CHIEF COMPLAINT
_________________________________
P: ________________________________
Q: ________________________________
R: ________________________________
S: ________________________________
T: ________________________________
III.
HISTORY OF PRESENT ILLNESS
1. _________
________________________
Onset: _________
________________________
Duration: ________
Frequency: _______
Location: ________________
Precipitating Factors: ________________________________
Quality: _________________
Radiation: ________________________
Severity: __
Aggravating Factors: ______
Alleviating Factors:___________________________________________
Previous Treatment for the Problem: ______________________
Associated Signs and Symptoms:
________________________________________
___________
Additional Notes:
________________
_________
IV.
Current Medications:
Generic
Brand

Medications: ________________________________
Pollen/Animals/Others: ______________________
Childhood Illness:
Rheumatic Fever - Age & Date of Diagnosis ____________
Polio - Age & Date of Diagnosis _____________
Chicken Pox - Age & Date of Diagnosis _____________
Measles - Age & Date of Diagnosis _____________
Mumps - Age & Date of Diagnosis _____________
Others: ____________________________________
Adult Illness:
Illness
HPN
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Psychiatric (Depression,
Anxiety, Suicidal Attempts)

Age

Surgical Procedures:
Date: _____________________________________________
Type of Operation: _____________________________
Kind of Injury: __________________________________
Purpose: ________________________________________
Previous Hospitalizations:
Date
Cause
Hospital

Screening Tests:
Test
Tuberculin Test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
X-ray/CT Scan/MRI
Coagulation Test

Date

Date of Diagnosis

Treatment

Result

PAST MEDICAL HISTORY

Dosage

Frequency

Immunizations:
BCG
DPT
Polio
Hepa B
Others: ____________________________________________
Allergies:
Food: ______________________________________

Purpose

Measles

V. MENSTRUAL AND OBSTETRIC HISTORY

LMP: ________________
PMP: ________________
Age of menarche: ____________
Period: Regular/Irregular
Character of flow: ___________________________________
Duration of period (range): ____________________________
No. of pads used per day: _____________________________
PMS: _____________________________________________
Age of Menopause: _________
Age of 1st coitus: _____
No. of sexual partners: _____
History of post-coital bleeding, pelvic infection, dyspareunia:
__________________________________________________
Birth control methods used:
Artificial
Natural

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condom
rhythm method
pills
withdrawal
spermicidal
abstinence
Others: ____________________________________
Length of time used: __________________________
Complications: ______________________________
Gravidity: _____
Parity: _____
OB Index:
_____________ Term
_____________ Preterm
_____________ Abortions/Miscarriages
_____________ Living Children
Date of Birth
Sex
Manner of Delivery

OB History: G ___ P ___ (T-P-A-L)

G1: When: __________, NSD or CS d/t: _________, delivered by _________,
where __________, M/F, weight __________, feto-maternal
complications __________, present status __________.
HIV Awareness: ________________________________________________________
VI. FAMILY HISTORY
Family
Member

Age

Health/Diseases

Age and
Date of
Dx

Cause of
Death

Father
Mother
Others
Medical Problems for any Blood-Relative
Disease
Relationship to Px

Age and Date of

Dx

Cancer
HPN
Diabetes
TB
Heart Disease
Stroke
Kidney
Arthritis
Blood Disorder
Asthma
Epilepsy
Mental Disorder
Galbladder dse
Substance Abuse
Thyroid Disease
Renal Disease
Hypercholesterolemia
Allergy
Suicide
VII. PERSONAL AND SOCIAL HISTORY
No. of years married: ______
No. of Children: _____
_____
Health Status of Children: _________________
____________
Highest Educational Attainment: ___________________________
Last year Of School: __________________________________________
Occupational History: ________________________________________
Occupational Hazards: _______________________________________

Smoking Habits
non-smoker
smoker
ex-smoker
No. of sticks/packs per day: ______________________________
Year started: __________
Year quitted: ___________
Alcohol Consumption
never
ocassionally daily
weekly
Alcohol type: ______
Amount consumed: ________________________
Nutrition
No. of meals per day:______________
Food preferences:
Coffee/Tea/Soda intake:
______________________
Nutrient Supplement: ______________________________
OTC: _______________________________________________ ____________
Prohibited Drugs: __________________________________
Substance Abuse: ___________________________________
Exercise:__________________
Regularity of Sleep:________________________
Interests: ______________________________________________________
Strengths: _____________________________________________________
Habits/hobbies: ____________________________________
Sources of stress: __
________________________
Sources of support:___________________________________________
Coping Strategies: ________ __ ______________________________
Military Service: ______________________________________________
Retirement: ___________________________________________________
Religious Affliation: __________________________________________
Safety Measures: _____________________________________________
Alternative Healthcare Practices: __________________________
Living Conditions:
No. of years in current residence: _______________
Previous place of residence: ______________________
Type of residence: ________ ______________________
No. of rooms: ______________________________________
No. of occupants: __________________________________
Relationship to occupants: ________________ _____
Source of Drinking Water: ________________________
Water Supply: _____________________________________
Garbage Disposal: _____________ ___________________
Fecal Disposal: ____
___________
Type 1/2/3
Pet/s: ______________________________________________
Personally gives bath to pets: Y/ N
General state of neighborhood:
__________
__________
VIII. REVIEW OF SYSTEMS
Constitutional
Fever
Weight gain/loss
Chills
Fatigue
Skin
Rashes
Itching
Lumps
Dryness
Color change
Changes in nails
Hair
Baldness
Excess hair
Head
Headache
Dizziness
Tenderness
Lightheadedness
Trauma
Syncope

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Eyes

Pallor
Pain
Redness
Double vision
Blurred vision
Photalgia
Lacrimation
Use of glass/lenses
Grade: ________________________
Started when: ________________
Frequency of use: ____________

Endocrine
Psychiatric

Ears
Hearing problem
Earache
Discharge (color/consistency): ____________
Itching
Mouth and Throat
Use of dentures Mouth sores
Bleeding gums
Sore throat
Hoarseness
Dysphagia
Toothache
Neck
Pain
Stiffness
Lump
Breast
Pain
Discharge
Lumps
.Periodic exam
Respiratory
Cough
Sputum color/quantity): ____
Hemoptysis
Dyspnea
Cardiovascular
Chest pain
Palpitations
Orthopnea
Edema
Cyanosis
Paroxysnal Nocturnal Dyspnea
Easy Fatigability
Gastrointestinal
Loss of appetite
Nausea
Vomiting
Hematemesis
Abdominal pain
Dysphagia
Hematochezia
Diarrhea
Hemorrhoids
Constipation
Stool: ________________
Renal:_______________________________________________
Dysuria
Polyuria
Nocturia
Gross Hematuria
Incontinence
Urinary Retention
Urinary Urgency
Tea-Colored Urine
In Males:
Reduced caliber of force of stream
Hesitancy
Dribbling
Genitalia
Pain
Swelling
Discharge (characteristics): ___________________
Ulcers
Itching
Peripheral Vascular
Leg cramps
Varicose veins
Musculoskeletal
Muscle weakness
Stiffness
Backache
Joint swelling
Muscle pain
Joint pain
Neurologic
Paralysis
Numbness
Tremors
Seizures
Memory Loss
Hematologic
Easy bruising
Bleeding

Polydipsia
Heat/cold intolerance

Polyphagia
Excessive sweating

Nervousness
Anxiety

Depression
Hallucinations

IX. PHYSICAL EXAMINATION

A. General Survey
Mood: _____________________________________________________
Distress/Unusual Position: _____________________________
Cooperative / Non-cooperative: _______________________
Irritated / Agitated / Pleasant: ________________________
Coherent: ________________________________________________
Oriented to time and space: ___________________________
Personal Hygiene: ______________________________________
Level of Consciousness: ________________________________
Apparent State of Health: ______________________________
acutely ill/ chronically ill/ frail / fit and robust
B. Anthropometric Measurement
Height: ____________________________________________
Weight: ___________________________________________
BMI:
Weight (kg)
__________= ______________________
Height (m2)
Underweight (<18.5)
Normal (18.5-24.9)
Overweight (25-29.9)
Obese I (30-34.9)
Obese II (35-39.9)
Obese III (>40)
Temperature: _______
Respiration: ________
Pulse: _____________
Blood Pressure: _____
Left Arm: _____________
Right Arm: ___________

C. Vital Signs
Oral Axillary Rectal
Normal
Labored
Regular R. Irregular
Irr. irregular
Lying Sitting Standing

D. Skin
Color:

Moisture:

normal
increased pigmentation
redness
cyanosis

loss of pigmentation
pallor
jaundice

dry
moist/wet
oily
Temperature:
generalized warmth/coolness
local warmth/coolness
Texture: rough/ smooth
Mobility & Turgor:
inc/dec/normal mobility
inc/dec/normal turgor
Lesions:
Location: _____________________________________________________

Page 3 of 7

Distribution: _________________________________________________
Patterns/Shapes: ____________________________________________
Type: _________________________________________________________
Color: _________________________________________________________
E. Head
Trauma: ___________________________________________
Size: __________
Shape: ________________________
Tenderness: _______________________________________
Condition of hair and scalp: ______________________
Symmetry: _________________________________________
Masses: ___________________________________________
F. Eyes
Visual Acuity:
Far:
(R) _________
(L) _________
Near:
(R) _________
(L) _________
Visual Fields (H-test): ________________________________
Accommodation: ____________________________________
Test of confrontation: ________________________________
Conjunctiva:
Color: ______________________________________
Discharge: __________________________________
Sclerae
Color: ______________________________________
Discharge: __________________________________
Cornea
Clarity: _____________________________________
Corneal Arcus: _______________________________
Lids: ______________________________________________
Position of eyes in orbits: _____________________________
Pupil
Size: (R) ____________
(L) _____________
Shape: _____________ Symmetry: ____________
Accommodation: ____________________________
Light reflex test (PERLA): ______________________
EOM: ______________________________________
Visual Field: _________________________________
Direct Reaction: ________ Consensual Reaction: _________
Fundoscopy
Red orange reflex: ___________________________
Disc: _______________________________________
Macula: ____________________________________
Blood vessels: _______________________________
G. Ears
Symmetry: _________________________________________
Swelling: _________________________________________
Redness: _________________________________________
Discharge: _______________________________________
Tenderness: ______________________________________
Hearing Impairments: ______________________________
Presence of Hearing Aid: ____________________________
Weber Test: ________________________________________
Rinne Test:
(R) AC _______
(BC) _______
(L) AC _______
(BC) _______
H. Nose
Symmetry: _________________________________________
Frontal, Maxillary sinus tenderness: ____________
Obstruction: _______________________________________
Congestion: ________________________________________
Lesions: ___________________________________________
Exudates: __________________________________________

Inflammation: ______________________________________
I.

Mouth & Throat

Lips:
Color: ____________ Moisture: __________
Lumps/ulcers/cracks/scales
Teeth/dentures: ____________________________________
Gums: ____________________________________________
Tongue:
Color: ___________ Texture: ___________
Deviation _______________________________
Pharynx: ___________________________________________
Lesions: __________
Erythema: __________
Exudates: _________
Tonsillar size: _________
Uvula: _______________________________________________
Tonsils: ______________________________________________
J. Neck
Symmetry: _________________________________________
Limitation of ROM: __________________________________
Tenderness: ________________________________________
JVP: ______________________________________________
Lymph nodes: ______________________________________
Size: _______________________________________
Mobility: ___________________________________
Tenderness: ________________________________
Borders: ___________________________________
Consistency: ________________________________
Thyroid Cartilage: _______ Cricoid cartilage: _______
Thyroid gland: ______________________________________
K. Chest and Lungs
1. Inspection
Comfort and Breathing Pattern: _______________________
Shape of the Chest: __________________________________
Chest Movement: ____________________________________
Use of Accessory Muscles of Breathing:
Deformities or Asymmetry
A/N Retraction of Interspaces on Inspiration
Retraction of the interspaces when breathing
Color of Patient (Lips and Nail Bed): ______________________
2. Palpation
Tender Areas: ________________________________________
Respiratory Expansion (10th rib): __________________________
Tactile Fremitus:
Increased
Decreased
Absent
3. Percussion
_________________________________________
4. Auscultation (Jamee)
________________________________________
Breath Sounds:_______________________________________________
Bronchophony
Whispered Petoriloquy
Egophony
L. Heart
1. Inspection
Precordial bulge or heave: ____________________________
PMI: ______________________________________________

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2. Palpation
PMI: ______________________________________________
Thrill: _____________________________________________
Location: ___________________________________
Timing in Cardiac Cycle (S/D): _________________
Mode of Extension / Transmission: ______________
Friction Rub: ______________________________________
3. Percussion
Cardiac Borders
Right (cm)

ICS/MSL
5th
4th
3rd
2nd

Left (cm)

4. Auscultation
S1 (M-loud, T-split): __________________________________
S2 (A,P-loud, P-split I): ________________________________
S3: _______________________________________________
Murmurs/ Accessory Heart Sounds:
Location:_______________ Timing:______________
Quality:________________ Pitch:_______________
Intensity:_______________ Radiation:___________
M. Breast
Symmetry:_________________________________________
Dimpling/Skin Retraction:____________________________
Swelling:_________________________________________
Discoloration (Skin changes):_________________________
Orange Peel Effect:_________________________________
Position and Characteristics of Nipple:___________________
Gynecomastia (Male):_______________________________
Mass:
Location:___________________________________
Size: _____________ Consistency:_______________
Tenderness:___________ Mobility:______________
Borders:____________________________________
N. Abdomen
1.General
Inspection
Skin
Scars: ___________________________________________
Striae:___________________________________________
Dilated Veins: __________________________________
Discoloration: __________________________________
Umbilicus
Contour: _____________________________________
Location: _____________________________________
Contour of Abdomen
Flat/Rounded/Protuberant/Scaphoid
Bulges: _________________________________________
Symmetry: _____________________________________
Distance of umbilicus from xiphoid process: __________
Abdominal Girth:_________________________________________
Peristalsis: ________________________________________________
Pulsations: ________________________________________________
Auscultation
Bowel Sounds

Frequency:__________ Character:__________
Bruit:____________________________________________
Venous Hum:_____________________________________
Friction Rub:______________________________________
Percussion
Splenic Dullness:____________________________________
Other Areas of Dullness: ______________________________
Palpation
Light Palpation
Abdominal tenderness: ______________________________
Muscular resistance: _________________________________
Deep Palpation
Masses: ______________________________
Location: ______________________________
Size: ______________________________
Shape: ______________________________
Consistency: ______________________________
Tenderness: ______________________________
Pulsations: ______________________________
Mobility with Respiration or Examining Hand:
______________________________
2. Liver
Percussion
Liver Span: ___________________________
Normal: 6-12 cm in (R) MCL
Palpation
Tenderness: _______________________________
Distance of Liver Edge from R Costal Margin in Midclavicular
Line: _______________________________________
Normal liver edge: soft, sharp, regular, smooth surface
Hooking
3. Spleen
Percussion
Splenic Percussion Sign: +/Palpation
Tenderness: ______________________________________________
Splenic contour: __________________________________________
Distance between lowest point and L costal margin:
______________________________________________
4. Kidney (Joyce)
Palpation (L)
Palpable/Not Palpable
Size: ______________________________________________________
Contour: _________________________________________________
Tenderness: _____________________________________________
Palpation (R)
Palpable/Not Palpable
Size: ______________________________________________________
Contour: _________________________________________________
Tenderness: _____________________________________________
Percussion
Costovertebral Angle Tenderness/ Kidney Punch:
_________________
5. Special Tests

Page 5 of 7

Rebound Tenderness: Rovsings / Blumberg

Costovertebral Tenderness
Shifting Dullness
Psoas Sign
Murphys Sign
O. Peripheral Vessels
Inspection
Amputation Visible joint swelling
Deformities Limitation of ROM
Tenderness Redness
Warmth
Edema
Capillary refill: __________________________________
Peripheral pulses: _______________________________
Grading of Pulses
Brachial (Joyce): ___________________________
Femoral (Cha): _____________________________
Popliteal (James): __________________________
Dorsalies Pedis (Jamee): __________________
Tibialis Posterior (Monique):_____________
Special Tests
Allen Test (Charmie): _____________________
Trendelenburg Test (Jamie):_____________
P. Male Genitalia
Penile Lesions:____________________________________
Scrotal Swelling:___________________________________
Testicles
Size:_________
Tenderness:________________
Masses:___________________________________
Varicocoele:_______________________________
Hernia:__________________________________________
Transillumination: ___________________________________
Q. Neurologic Exam
Mental Status Examination
A. Awareness
Orientation
Name: Season Date Day Month Year
Name: Hospital Floor Town State Country
Level of Consciousness:
B. Speech (Normal, dysphasia, dysarthria, dysphonia)
C. Language
Name: Pencil Watch
Repeat: No ifs ands or buts
D. General Knowledge
Knowledge of current events, vocabulary
(Historical events, 5 last presidents, 5 largest cities)
E. Memory
Immediate, recent, remote
F. Registration (Retention and Recall)
Identify: Object 1 Object 2 Object 3
Attention and Calculation
(100-7): 93 86 79 72 65
Recall
Recall: Object 1 Object 2 Object 3
G. Reasoning
Judgment, Insight, Abstraction (interpretation of
proverbs)
H. Object Recognition

Agnosia (Visual, tactile, auditory autotopagnosia,

anosognosia)
Praxis (Ideomotor, Ideational)
Perception (Delusion, Hallucination, Illusion,
Astereognosis, Agraphestesia)
I. Follows Command
Take this paper. Fold it in half.
Place it on the table
Obey written Command.
Write a sentence
Copy a design.
Total: _____________________________________________
Cranial Nerve Examination
CN I
Identify odorant
CN II
Visual acuity:_____________ Visual Field: ________________
Fundoscopy: _______________________________________
CN III, IV, VI
Size and Shape of Pupil: ______________________________
Light Reaction
Accommodation
EOM:
Paresis
Nystagmus
Saccades
Oculomotor Ataxia
Diplopia
Other: _____________________
CN V
Ophthalmic
Maxillary
Mandibular
Corneal Reflex
Jaw Clench
CN VII
Eyebrow Elevation
Forehead Wrinkling
Eye Closure
Smiling
Cheek Puffing
CN VIII
Hear finger rub or whispered voice
Rinne:___________________ Weber: ___________________
CN IX, X
Palate and Uvula: ___________________________________
Gag Reflex
CN XI
Shoulder Shrug (against resistance)
Head Rotation (against resistance)
CN XII (Tongue)
Atrophy
Fasciculation
Position with protrusion:______________________________
Strength:___________________________________________
Motor Examination
Involuntary Movements
Symmetry
Atrophy
Gait
Spasticity
Rigidity
Flaccidity
Clonus
Carpopedal Spasm
Tics
Tremors
Athetosis

Page 6 of 7

Others

Babinski

Tone
Description: ________________________________________
Flaccidity
Spasticity
Muscle Strength
(R)
Shoulder Flexion
Extension
Abduction
Adduction
IR/ER
Flexion at the Elbow
Extension at the elbow
Extension at the wrist
Squeeze 2 of your fingers as hard as possible
Finger Abduction
Opposition of the thumb
Flexion at the hips
Adduction at the hips
Abduction at the hips
Extension at the hips
IR/ER
Extension at the knee
Flexion at the knee
Dorsiflexion at the ankle
Plantar Flexion

(L)

Sensory
Pin prick
Touch
Two point discrimination
Sense of Position
Vibratory Sense
Superficial sensation
Deep Sensation

Coordination and Gait

Rapid Alternating Movements
Point to point movements
Romberg
Gait
Walk across the room, turn and come back
Walk heel-to-toe in a straight line
Walk on heels in a straight line
Walk on toes in a straight line
Hop in place on each foot
Shallow knee band
Rise from a sitting position
Reflexes
Deep Tendon
Biceps
Triceps
Brachioradialis
Knee
Ankle
Superficial
Abdominal
Cremasteric
Reflexes in Infants
Grasp
Suck
Moro
Rooting
Tonic neck

Page 7 of 7