HISTORY

Date of Interview: ______________________________

Time of History: _______________________________
Informant: ____________________________________
Relationship to the Patient: ______________________
% Reliability: _________
General Data:
Patients Name: _____________________________
Age: ______
Birthdate: _____________
Birthplace:_______________________
Sex: _______
Address:_________________________________________
Nationality: ______________
Religion:_________________________
Occupation: __________________________
Date of Admission: ______________________
Time of Admission: ______________________
No. of times admitted at OM: ______________
Chief
Complaint:_______________________________________
History of Present Illness:
Onset: _______________________________
Duration: _____________________________
Frequency: ___________________________
Setting at which the Symptom Occurred:
_______________________________________
Manifestations: _________________________
Location: ________________________
Precipitating Factors: _______________
Quality: __________________________
Radiation: ________________________
Severity: _________________________
Aggravating Factors: ______________________
Alleviating Factors: _______________________
Previous Treatment for the Problem: ________________
Associated Signs and Symptoms: ___________________
______________________________________________
Pertinent Positives and Negatives: _____________________
________________________________________________
Additional Notes:
__________________________________________
_______________________________________________
_______________________________________________
PERSONAL HISTORY
Gestational History: (<2y/o)
Age of mother during pregnancy: _____________________
Mothers OB index:________
Mothers health, nutrition, drug intake, exposure:_________
Duration of gestation:__________
Birth: (<2y/o)
Term/Premature/Post-mature: _______
Manner of delivery: __________
Person who attended delivery:______
Birth weight:___________
Neonatal History: (<2y/o)
APGAR score: _______
Spontaneous respi? ______
Cyanosis/Pallor: _____
Cry: _______
Jaundice (age of onset):________

Convulsions:_______
Hemorrhage:_______
Respi/feeding difficulties: ______________
Congenital abnormalities: ____________
Birth injury: ________________
Feeding History
Infancy (<2y/o):
Type of feeding:
Breastfeeding:____________________________
Formula: ________________________________
Complementary foods
Age introduced: ___
Foods initially & subsequently given: __________
Frequency of feeding per day: _______________
Usual food intake
Breakfast:_______________
Lunch: _________________
Dinner: ________________
Snacks: _______________
Compute actual caloric intake: ____ & Compare w/ RENI __
Food intolerance: _______
Multivitamin & Iron supplements: _________________
Caregiver: _________
Childhood & Adolescents (2-20 y/o):
Appetite: _______________
Usual food intake and amount per day:
Breakfast: ____________________________
Lunch: _______________________________
Dinner: _______________________________
Snacks: _______________________________
Compute actual caloric intake: ____ & Compare w/ RENI __
Food likes or dislikes: ______________
Feeding difficulties: _________________
Multivitamin & Iron supplements: _________________
Development/Behavioral History
Young Children (1-5 y/o):
Use Devt. Checklist in book (p.110): ___________________
Dental eruption: ______________
Urinary continence (day/night): ______________
Toilet training: started______, completed ____________
Head banging: ______________
Phobias: ____________ Night terrors:________________
Middle Childhood (6-11 y/o):
School performance: _____________
Sexual development (Tanners): _______________
Adolescence (10-20 y/o):
HEADSSS: Home ________, Education ________,
Eating habits ________, Activities _________,
Drugs __________, Sexual _________,
Suicidal ________
Sexual Devt (Tanners): ______________
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
condom
rhythm method
pills
withdrawal
spermicidal
abstinence
Others:_________________________________
Length of time used: _________
Complications:____________________________
Gravidity: ______ Parity: _______
OB Index: ____Term, ___ Preterm,
_____Abortions/Miscarriages, ____ Living Children
G1: When _________, NSD or CS d/t _________, delivered by
_________, where _________, M/F, weight _________,
fetomaternal complications _____________________, present
status __________.
Past Illnesses
Allergies:
Food: ___________________________________
Medications: _____________________________
Pollen/Animals/Others:______________________
Childhood Illness:
rheumatic fever polio
chicken pox
measles
mumps
pertussis
others: ______________________________
Describe clinical course:
_______________________________________________
Adult Illness:
Illness
Age
Date of
Diagnosis
Asthma
Eczema
Hypertension
Stroke
Renal
TB
DM
Cardiac
GI
STD
Others
Surgical Procedures:
Date: _______________________________
Type of Operation: _____________________
Purpose: _____________________________
Previous Hospitalizations:
Date
Cause
Hospital
Treatment

Screening Tests:
Test
Tuberculin test
Pap Smear
Mammogram
Occult blood in
stool
Cholesterol test
Urinalysis
Xray/CT Scan/MRI
Others

Date

Result

Injuries: _________________________________________

Immunization History & Tuberculin Test

BCG: ________________________________
DPT: __________________________________
Polio: _________________________________
Hepa B: ________________________________
Measles: _______________________________
Others: ________________________________________
Adverse effects: ______________________________
Tuberculin Test: ______________________________
Family History:
Family
Age Occupation
Member

Health/
Diseases

Age &
Date of
Dx

Cause
of
Death

Father
Mother
Siblings

Medical Problems for any blood-relative

Rel. to Px

Age & Date of

Dx

Course of
Illness

Tuberculosis
Diabetes
Syphilis
Cancer
Epilepsy
Rheumatic
fever
Allergy
Asthma
Hypertension
Heart Disease
Stroke
Kidney
Disease
Arthritis
Blood
Disorder
Mental
Disorder
Others:
Socioeconomic History
Living Conditions:
No. of years in current residence: _______
Previous place of residence: ____________
Type of residence: ___________________
No. of rooms: _______________________
No. of occupants: ____________________
Relationship to occupants: _________________
Economic Circumstances:
Members of family who work: ____________
Source of funds: _______________________
Environmental History
Exposure to cigarette smoke: ____________________
Other pollutants: ________________________
Source of Drinking Water: ________________
Source of Washing water: ____________________
Garbage Disposal: ______________________
Fecal Disposal: ____________________
Pet/s: _______________Personally gives bath to pets? Y/N
General State of neighborhood: ______________
Others:

No. of years married: ______

Health Status of Spouse: ______________
No. of Children: _______
Health Status of Children: ________________________
Highest Educational Attainment: ____________________
Occupational History: _____________________________
Occupational Hazards: ____________________________
Smoking Habits:
non-smoker
smoker
exsmoker
No. of sticks/packs per day: _________
Year started: ______
Year quitted: ______
Alcohol Consumption
never
occasionally
daily
weekly
Alcohol type: ___________________
Amount Consumed: ______________
OTC: _______________________
Prohibited Drugs: _____________
Substance Abuse: _____________
Exercise: ___________________________________
Regularity of Sleep: ___________________________
Habits/hobbies: ______________________________
Sources of Stress: ___________________________
Coping Strategies: ___________________________
REVIEW OF SYSTEMS
General:
Fever
Weight gain/loss
Chills
Fatigue
Activity level: ____________________
Appetite: _____
Delay in growth: _______
Skin:
Rashes
Itching
Lumps
Dryness
Color Change Changes in Nails
Hair:
Baldness
Excess Hair
Head:
Headache
Dizziness
Lightheadedness
Trauma
Syncope
Tenderness
Eyes:
Pain
Redness
Double Vision
Blurred Vision
Use of Glass/Lenses
Photalgia
Lacrimation
Ears:
Hearing Problem
Earache
Discharge (color/consistency) ____________
Tinnitus
Vertigo
Nose and Sinuses:
Epistaxis
Nasal stuffiness
Discharge (color/consistency): ____________
Itching
Mouth and Throat:
Use of dentures
Mouth sores
Bleeding Gums
Toothache
Sore throat
Hoarseness
Dysphagia
Salivation
Neck:
Pain Stiffness
Lump
Breast:
Pain Discharge

Lumps
Periodic BSE
Respiratory:
Cough
Sputum (color/quantity)
________
Hemoptysis
Dyspnea
Wheezing
Cardiovascular:
Chest Pain
Palpitations
Orthopnea
Edema
Cyanosis
Paroxysmal Nocturnal Dyspnea
Easy Fatigability
Gastrointestinal:
Bowel characteristics: ______________________________
Loss of appetite
Nausea
Vomiting
Hematemesis
Abdominal pain
Diarrhea
Hematochezia
Constipation
Excessive belching/passing of gas
Pica
Passage of worms
Encopresis
Food intolerance
Renal:
Urine characteristics:_______________________________
Burning sensation
Dysuria
Enuresis
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
Muskuloskeletal:
Muscle weakness
Stiffness
Backache
Joint swelling
Muscle pain
Join Pain
Limitation of motion
Limping
Neurologic:
Paralysis
Numbness
Tremors
Convulsions
Memory Loss
Sleeping problems
Mental deterioration
Hematologic:
Easy bruising
Bleeding
Pallor
Endocrine
Polydipsia
Polyphagia
Heat/cold intolerance Excessive sweating
Psychiatric:
Nervousness
Depression
Anxiety
Hallucinations
Eating problems
Mood changes
Personality/Behavior changes
School failures
Temper outbursts
PHYSICAL EXAMINATION
General Survey:
Level of activity: ________________
Distress/ Unusual Position: ___________
Ambulatory/Bedridden
Nutritional state: ___________
Ill-looking? ________
Mood: ______________
Cooperative/ Non-cooperative
Irritable/agitated/pleasant
Coherent: _________

Oriented to time and space: _______

Personal Hygiene: _______________
Level of Consciousness: ______________
Vital Signs:
Temp: ________
Oral Axillary Rectal
RR: _________
Normal Labored
PR: ___, Volume: _______ Regular R. Irreg. Irr. irreg.
BP (>3y/o) R arm: ______ Lying Sitting Standing
BP (>3y/o) L arm: _______, Ankle: _________
Anthropometric Data:
Weight: ____________
Length (<2y/o), Height (>2y/o): ____________
BMI: ______________
Head circumference (<3y/o): _______________
Chest circumference: ______________
Arm span: _____________
Upper segment: ___________, Lower segment: _________
Skin:
Color: _____________
Tissue turgor: _____________
Loss of subcutaneous tissue: _____________
Rash/eruptions: ____________________
Hemorrhages: ______________
Edema: _____________
Jaundice: ___________________
Head:
Hair:

Quantity________
Color ____________
Texture ______________
Lice/nits: ______________
Strength ____________
Size: _________ Shape: _____________
Trauma: ______ Tenderness:____________ Lesions: _____
Fontanels: ______________
Symmetry: ___________________________
Masses: _____________________________
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: ______________ Iris: ________________
Position of eyes in orbits:
______________________________
Pupil:
Size: (R) __________ (L) ___________
Shape: ____________ Symmetry: ___________
Accommodation: _______________
Light reflex test (PERLA): ________________
EOM: ________________________
Visual Field: ____________________________
Direct Reaction: ____ Consensual Reaction: ______
Fundoscopic
Red orange reflex: ______________

Disc: ________________________
Macula: _____________________
Blood vessels: _________________
Ears:
Symmetry: _______________
Swelling: ______________________________
Redness: ______________________________
Discharge: ______________________________
Tenderness: _____________________________
Hearing Impairments: _______________________
Presence of Hearing Aid: _____________________
Weber Test: ______________________________
Rinne Test: (R) AC __________ BC ___________
(L) AC __________ BC ___________
Nose:
Symmetry: ___________________________
Frontal, maxillary sinus tenderness: _________________
Obstruction: __________________________
Congestion: __________________________
Lesions: _____________________________
Exudates: ____________ Inflammation: ________________
Throat:
Lips: _____________________
Teeth (20 by 2y/o): _______________________
Gums: _______________________________
Tongue: _____________________________
Pharynx: Lesions: _________ Erythema: _________
Exudates: ________ Tonsillar Size: _________
Neck:
Symmetry: _________________________
Limitation of ROM: __________________
Tenderness: _________________________
JVD: ______________________________
Lymph nodes: ________________________
Size: _____________
Mobility: ___________
Tenderness: _____________
Borders: ________________
Consistency: _____________
Thyroid cartilage: _____________ Cricoid cartilage:
______________
Thyroid gland: ________________
Chest and Lungs
Inspection
Comfort and Breathing Pattern: _____________________
Size and Shape of Chest (CC<HC in 9-12mos; CC>HC by
1y/o; Transverse >AP diameter in <2y/o): ______________
Chest Movement: ________________________________
Use of Accessory Muscles of Breathing: ______________
Deformities or Asymmetry: ______________________
A/N Retraction of Interspaces on Inspiration: _________
Impairment of Respiratory Movement: ______________
Color of Patient (Lips & Nail Bed): ___________________
Palpation
Tender Areas: ________________________________
Respiratory Expansion (10th rib): Symmetry Yes No
Tactile Fremitus: Symmetry
Increased
Decreased Absent
Percussion: ____________________________________
Auscultation
Breath Sounds: _________________________________
Bronchophony Whispered Petoriloquy
Egophony

Heart:
Inspection
Dynamic/Adynamic
Precordial bulge or heave: __________________
PMI (4th LICS MCL up to 7y/o; then 5th LICS MCL): _______
Palpation
PMI: __________________________
Thrill: _____
Location: _________________
Timing in Cardiac Cycle (S/D): ______________
Mode of Extension/Transmission: ____________
Friction Rub: ___________________
Auscultation
S1 (M-loud, T-split): ___________________
S2 (A,P-loud, P-split I): ___________________
S3: _________________________
Murmurs/Accessory Heart Sounds:
Location: ___________ Timing: ____________
Quality: ____________ Pitch: _____________
Intensity: ___________ Radiation: ___________
Breast:
Symmetry: _____________
Dimpling/Skin Retraction: _____________________
Swelling: ____________________
Discoloration (Skin changes): _________________
Orange Peel Effect: _________________
Position and Characteristic of Nipple: _________________
Gynecomastia (Male): _________________
Mass:
Location: _____________________
Size: ___________Consistency: ____________
Tenderness: ______________ Mobility: _______
Borders: _________________
Abdomen:
Inspection
Irregular Contours: ____________ Scars
Discoloration: ________________
Bulges: _____________________
Shape: _____________________
Striae: ______________________
Distance of umbilicus from xiphoid process: __________
Abdominal Girth: __________________
Auscultation
Bowel Sounds: Frequency: ___________ Character:
____________
Bruit: ___________________
Venous Hum: ______________
Friction Rub: _______________
Percussion
Liver Span: _______________ Normal: 6-12 cm in (R)MCL
Splenic Dullness: ______________
Other Areas of Dullness: _______________
Special Tests
Rebound Tenderness: Rovsings, Blumberg
Costovertebral Tenderness
Shifting Dullness
Psoas Sign
Murphys Sign
Male Genitalia:
Penile Lesions: _______________
Scrotal Swelling: _______________________
Testicles
Size: ________ Tenderness: ___________
Masses: ______________
Varicocoele: _________________

Hernia: ________________
Transillumination: ________________
Extremities:
Amputation
Deformities
Tenderness
Warmth

Visible joint swelling

Limitation of ROM
Redness
Edema

Capillary refill: ______________

Peripheral pulses: ___________
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: __________

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 bend
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
Babinski

Motor Examination
Involuntary Movements
Symmetry
Atrophy
Gait
Paresis
Paralysis
Spasticity
Rigidity
Flaccidity
Clonus
Carpopedal Spasm
Tics
Tremors
Athetosis
Others

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

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
Coordination and Gait
Rapid Alternating Movements
Point to Point Movements
Romberg

(L)