A. GENERAL DATA (Time:_____) o Nausea? _______________________________ NAME: _________________________ o Sporadic? _______________________________ AGE: __________ SEX:____________ o Postprandial? _______________________________ RACE: _________ RELIGION:_______ o Projectile? _______________________________ CIVIL STATUS: ___________________ Amount of vomitus: _________ _______________________________ OCCUPATION: ___________________ Describe vomitus: _______________________________ ADDRESS: _______________________ _______________________________ o Yellowish-mucoid (stomach) BDAY: __________________________ o Solid food? Laboratory results: (w/ units of measurement) BPLACE: ________________________ o White, mostly saliva o CBC: _________________ DATE OF ADMXN: ________________ o U/A: _________________ PLACE OF ADMXN: ________________ Aggravating: o Stool exam: _____________ o Sitting up? Position: ______ II. CHIEF COMPLAINT: o Lying down? Pertinent Neg: __________________ o Carrying heavy objects? _______________________________ III. HISTORY OF PRESENT ILLNESS o Flashing lights? _______________________________ Onset: _________________________ o Walking? _______________________________ Nature/ Char: o Talking? _______________________________ Fever: o Eating? _______________________________ Relieving: _______________________________ Temperature:______C o Lying down? Effects on: o Intermittent - Relieved by meds? o Warm/ cold compress? o Work:________________ Minutes: ____________ o Lifestyle: _______________ goes down to temp: ______C o Physiologic fxn: ___________ for: ____ hours Meds: o Continuous IV. PAST HISTORY Dosage Generic Brand name Childhood illnesses: o Remittent # of tab, name mg, hours, o Measles (tipdas): ______y.o. Pain: (headache, etc) # of o Chickenpox (hangga): ___y.o. dosages: Pain score: _____ out of 10 o Mumps (bayu-ok): ______y.o. Location: ______________________ 1. o Smallpox (bulutong): ____y.o. o Transferred? o Dengue: ______y.o. to: ______________ Immunizations: 2. o Constant? o BCG o DPT 3. o Radiating? o MMR o Throbbing? o Hep B o Colicky? (kumot-kumot, on & off) 4. o Pneumococcal o Pulsating? (eg. Migraine) o OPV o Gnawing? (ngut2x eg. Hunger pangs) 5. o Health center? o Aching? (cont. kumot) o Private clinic? o Burning? (hapdos) Adult Illnesses: o Sharp? Medical: o Dull? (ngol2x, numb) RESPONSE TO MEDS: Yr/ Hospital Dx/ Prob Tx _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ Smoking: Psychiatric Disorders: - Since: ___________________ Surgical: o Extreme sadness? - Packs/day: ______________ Yr/ Hospital Dx/ Prob Tx o Suicidal? - Frequency: _______________ - PACKS/ YR ___________ Screening Tests: = (Age now - Age start )x(pack/day) year results Sleeping habits: _________________ X-ray Eating patterns: _________________ Bowel Movements: _______________ Hep B Titer Urination:_______________________ Lipid Panel Exercise: ______________________ OB-GYNE: Allergies: MENARCHE FBS o Drugs: ________________ Age: _____ Duration: _____________ o Food: _________________ HBA1c Character of Flow: Light/ Mod/ Heavy o Environmental: ___________ Pads/day:_______________________ SUBSEQUENT MENSES Spouse: o DM Regular:_________________________ - Occupation: _____________ o Hypertension Pads/day: _______________________ - Age: ________ o Arthritis Duration: _______________________ - Health: _______________ o Heart Dses Interval: ________________________ o TB Days of Menstrual Cycle: ___________ Children: o Cancer Associating Symptoms: o Asthma 1st 2nd 3rd Dysmenorrhea: _____ Pain Scale: ____ o Anemia Age Intervention: ____________________ o Stroke sex ________________________________ o Kidney dses health Meds: ________________________ MENOPAUSE VI. FAMILY HISTORY V. PERSONAL & SOCIAL HISTORY Age: ______ HRT used: ____________ FATHER: Occupation: ___________________ _______________________________ Age: _____ Health: ______________ Education: ____________________ Menopausal S/s: _______________________________ Religion: (Refer to Gen. Data) - Hot flashes ( ) _______________________________ Hobbies: _______________________ - Irritability ( ) Meds: (Name/ Dose/ Compliance) Home situation: - Fatigue ( ) _______________________________ o Living alone - Others: __________________ _______________________________ o Living with: _____________ _______________________________ MOTHER: o Apartment o Own house Age: _____ Health: ______________ G( ) T( ) P( ) A( ) L( ) _______________________________ o In-laws house _______________________________ G1 G2 G3 G4 Meds: (Name/ Dose/ Compliance) HABITS Year Alcohol ingestion: ________________ _______________________________ AOG - Since: ___________________ _______________________________ Duration of Labor - # of bottles: ______________ Rank in the family: _______________ Method - Frequency: _______________ SIBLINGS: (Age/ Health/ Meds) of Del - Cut down: _______________ Rank Place of - Annoyed: ________________ Age Del Wt: - Guilt feelings: _____________ sex Sex - Eye opener: ______________ health - Stop: ____________________ meds Cx: Heredofamilial Dse: ______________ _______________________________ REVIEW OF SYSTEMS General. Usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails Head, Eyes, Ears, Nose, Throat (HEENT) Head. Headache, head injury, dizziness, lightheadedness Eyes. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids Nose and sinuses. Frequent colds, nasal stuffiness, discharge, or itching hay fever, nosebleeds, sinus trouble Throat. Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, last dental examination, sore tongue, dry tongue, frequent sore throats, hoarseness Neck. Lumps, swollen glands, goiter, pain or stiffness in the neck Breasts. Lumps, pain or discomfort, nipple discharge, SBE Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray, asthma, bronchitis, emphysema, pneumonia, TB Cardiovascular. Heart trouble, high BP, rheumatic fever, heart murmurs, chest pain or discomfort, palpations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past ECG or other heart test results Gastrointestinal. Trouble swallowing, heartburn, appetite nausea, bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling Genital. Male hernias, discharge, from or sores on the penis, testicular pain or masses, history of STDs and their treatments, sexual habits, interest, function, satisfaction, birth control methods, condom use, problems, exposure to HIV infection Female age at menarche, regularity, frequency, and duration of periods, amount of bleeding, intermenstrual bleeding or after intercourse, LMP, dysmenorrheal, premenstrual tension, age at menopause, menopausal symptoms, postmenopausal bleeding, vaginal discharge, itching, sores, lumps, STDs and treatments, number of pregnancies, number and type of deliveries, number of abortions, complications of pregnancy, birth control methods, sexual preference, function, satisfaction, problems, dyspareunia, exposure to HIV infection, if born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected joints, muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness or limitation in motion or activity, duration & any history of trauma Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements Hematologic. Anemia, easy bruising or bleeding, past transfusions and or transfusion reactions Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant GENERAL SURVEY Level of consciousness: conscious/alert, confused, lethargic/somnolent, Sexual development : normal, precocious puberty, hypogonadism, stupor/semi-coma, comatose virilism, delayed puberty Mental state & mood: orientation to time, place and identity, coherent, Signs of distress: labored breathing, flaring of ala nasi, wheezing, incoherent, cooperative, uncooperative, hostile, depressed, apathetic, coughing, sweating, anxious face, protectiveness of painful parts, nervous fidgety movement Gait: ambulatory, non-ambulatory, trunk posture, gait sequence, arm Physical appearance in relation to age: appropriate, younger, older movement, hemiplegic, steppage, tabetic, parkinsonian, scissors Posture: normal position, lordosis, kyphosis, scoliosis, decorticate VITAL SIGNS: rigidity, decerebrate rigidity, opisthotonus BP: ___mmHg right/ left; arm/leg; sitting/supine State of nutrition: underweight, emaciated, cachectic, normal, PR: ___bpm right/ left radial; regular normal force (or +2) : overweight, obese, extremely obese weak, thready, strong, forceful, bounding Habitus/Body build: mesomorphic, ectomorphic, endomorphic, sthenic, RR: ___cpm regular, silent, normal depth asthenic, hypersthenic Temp: ___C right/ left, axillary/oral/rectal Stature/Height Involuntary movements: tics, chorea, athetosis, dystonia, tremors Ht: ____cm (resting, intention, postural) Wt: ____ kg Speech: normal, hoarse voice, aphonia, slurred, scanning, echolalia