Ateneo School of Medicine

Jobel Fernandez,

R.N (M.D, M.P.H)

Course: _________________________________ Module:______________________ Ward:___________

Date and time of interview:___________ Date and Time of admission: _______________________

Source of information:__________________________ Reliability:___________________________
Name: _______________________________________ Birthdate: _________________________
Age:___________
Sex: O F O M
Religion:_________
Civil Status: ______
Address: ___________________________
Chief Complaint: _______________________
History of Present Illness:

Onset- gradually? How did it develop? Immediately?

Cause of onset? Happened before? Compare
Location- diffused? Localized? Radiating?
Duration- Constant? Episodic? the same? Worsens?
Character- dull, sharp, aching, gnawing, constricting?
Association- other s/s which appeared at the same time?
Aggravating/Alleviating- what worsens? Lessens?
Treatment- Outcome? Immediate relief?
Severity- rate. Interferes with ADL, work, sleep?

Ateneo School of Medicine

Jobel Fernandez,

R.N (M.D, M.P.H)

Course: _________________________________ Module:______________________ Ward:___________

Past Medical History (Adult):

General
Previous illness/Congenital defect
________________________________________________________________________
Prenatal
G_______ T__________ P_________ A___________ L ___________
Prenatal Visit:___________________________ TT: ____________________________
Illness/ Complications: ____________________________________________________
Lifestyle/ Vice during pregnancy: ____________________________________________
Dose & # of pills/day

For how long?

Reason for taking

Medications ___________________ _________________ _______ _______________

by mother

___________________ _________________ _______ _______________

Natal
Age of mother: ___ Complications: ___________________________________________
NSVD ( ) place: _______________ CS ( ) reason: ________________ place: _________
Illness/disease of newborn: _________________________________________________
Weight: ________ Length: ___________ 1st APGAR: _____ 2nd APGAR: ____________
Postnatal
Breastfed for how long? ______ Bottlefed started on? __________ Milk_____________
Immunization: ( )BCG ( )HepaB__ ( )DPT__ ( )OPV__ ( )MMR/measles others:_________
Developmental milestone
6 months

____ sits unsupported ____rolls prone to supine ____stranger anxiety ___babbles

9-10 months _____ crawls/

1 yr ____throws

cruises _____ stands with help ____peek-a-boo ___ mama/dada/bye2

ball ____ walks unsupported ____2-3 words ____cooperates w/ dressing

Wt on 1st yr:______ Ht on 1st yr: ________ Wt on 2nd yr:_______ Ht on 2nd yr:_________

Childhood diseases: ______________________________________________________
Dose & # of pills/day

For how long?

Reason for taking

Medications ___________________ _________________ _______ _______________

Ateneo School of Medicine

Jobel Fernandez,

R.N (M.D, M.P.H)

Course: _________________________________ Module:______________________ Ward:___________

Personal History:
Hometown: _____________________________________________
Education: _____________________________________________
Play: __________________________________________________
Guardian: _______________________________________________
Hygienic practices:_________________________________________
Usual ADLs: _____________________________________________
Usual meal:______________________________________________

How long: _____

# in family:____
# of siblings:___

Family History
Members
Age
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____
_____________ ____

Occu./Edu.
____________
____________
____________
____________
____________
____________
____________

Disease/Status (alive) Cause of death (deceased)

___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________
___________________ _____________________

Encircle if (+): DM, Asthma, Psych, CAD, HTN, TB, Cancer, Clotting disorders
Others: __________________________________________________________________

MISCELLANEOUS:

Ateneo School of Medicine

Jobel Fernandez,

R.N (M.D, M.P.H)

Course: _________________________________ Module:______________________ Ward:___________

SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL
Recent weight gain;
how much____
Recent weight loss:
how much____
Fatigue
Weakness
Fever
Night sweats

NERVOUS SYSTEM
Headaches

PSYCHIATRIC
Depression

Dizziness

Excessive worries

Fainting
Numbness or tingling
Memory loss

MUSCLE/JOINTS/BONES
Numbness
Joint pain
Muscle weakness
Joint swelling
Where?
EARS
Ringing in ears
Loss of hearing

STOMACH AND INTESTINES

Nausea
Heartburn
Stomach pain
Vomiting
Yellow jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools

EYES
Pain
Redness
Loss of vision
Double or blurred vision
Dryness

SKIN
Redness
Rash
Nodules/bumps
Hair loss
Color changes of hands or feet

Difficulty falling asleep

Difficulty staying asleep
Difficulties w/ sexual arousal
Poor appetite
Food cravings
Frequent crying
Sensitivity
Thoughts of suicide / attempts
Stress
Irritability
Poor concentration
Racing thoughts
Hallucinations
Rapid speech
Guilty thoughts
Paranoia
Mood swings
Anxiety
Risky behavior

THROAT
Frequent sore throats
Hoarseness
Difficulty in swallowing
Pain in jaw

BLOOD
Anemia
Clots

HEART AND LUNGS

Chest pain
Palpitations
Shortness of breath
Fainting
Swollen legs or feet
Cough

KIDNEY/URINE/BLADDER
Frequent or painful urination
Blood in urine
Women Only:
Abnormal Pap smear
Irregular periods
Bleeding between periods
PMS

OTHER PROBLEMS:

Ateneo School of Medicine

Jobel Fernandez,

R.N (M.D, M.P.H)

Course: _________________________________ Module:______________________ Ward:___________