MEDICAL EXAMINATION FORM1

DATE:__________________
TIME:_________________
NAME:
_________________________________________________________
ADDRESS:____________________________________________________
___
GENDER:_____________________
NATIONALITY:_______________
OCCUPATION:_________________
RELIGION:__________________
PLACE OF BIRTH:_______________
BDATE:_____________________
CIVIL STATUS:_________________
AGE:
______________________
NO. OF ADMISSION:____________
DATE of
adim:_______________
INFORMANT:_________________
%
RELIABILITY:_______________

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

Onset of
illness:_____________________________________________
Manner of
onset:____________________________________________
No. of
mins./hours/days/weeks:________________________________
PQRST of Pain:
o P- precipitating
factors/aggravation/palliative/alleviating or
relieving ? medication taken?any relief?how long?
o Q-quality/character/type of symptom
(sharp/throbbing/pressing/crampy/burning/heavy/dull
)
o R-region/location/radiation of symptom
o S-severity/intensity of symptom
(mild,moderate,severe) (1-10)
o T-timing (When/at what time did the pain start? How
long did it last? How often does it occur: hourly?
daily? weekly? monthly? Is it sudden or gradual?)
Symptoms:

PAST MEDICAL HISTORY

Childhood
illnesses:__________________________________________
Adult
illnesses:______________________________________________
Recent/Previous/Related
illness:________________________________
Immunization:____________________________________________
__
Surgeries:
__________________________________________________
Allergies:
__________________________________________________
Blood transfusion:
___________________________________________
Medication:______________________________________________
__
FAMILY HISTORY
Father:___________________________________________________
_
Mother:
__________________________________________________
Siblings:
__________________________________________________
Any relatives:
_______________________________________________
Heredofamilial
diseases:______________________________________

PERSONAL AND SOCIAL HISTORY

Educational
attainment:_______________________________________
Cigarette use:___________________
o Sticks per day:_____________ No. of years
smoked:__________
o Pack years (No. of pack-years = # of cigarettes
smoked per day # of years
smoked)/20):____________________________________
Alcohol use:
_______________________________________________
Substance abuse:
___________________________________________
Lifestyle:
__________________________________________________
Food preference:
____________________________________________
Occupation History:

House:
o Type: _____________________
o Residents:__________________
o Ventilation: ________________
o Windows__________________

SHERYLYN

MEDICAL EXAMINATION FORM2

o Water supply: ______________
o Environment:_______________
Sleep pattern:
______________________________________________
o Nap:__________________________________________
_
Garbage
collection:__________________________________________
OB-GYNE HISTORY
Menarche age:_______________
Flow:
________________________
Menstrual cycle: __________________
Duration:_________________
Interval:__________________________________________________
_
Remarks:
__________________________________________________
OB surgeries:
_______________________________________________
Contraception:
_____________________________________________
LMP:_________________
OB score:
gravida:______
parity:________
term:
_________
preterm:______ abortion:_______
living:________
G1

G2

G3

G4

GENDER
DATE
FULL/PRETE
RM
TYPE OF
DELIVERY
IN-CHARGE

Bowel Elimination:
______________________________________
Genitourinary
( ) Dysuria; ( ) Anuria; ( ) Polyuria; ( ) Oliguria; ( ) Hematuria;
( ) Incontinence; ( ) Dribbling; ( ) Urinary Frequency; ( )
Flank/suparpubic pain; ( ) Passage of stone; ( ) discharge;
Remarks: ____________________________________________________
Musculoskeletal
( ) Muscle pain; ( ) Joint pain & Stiffness; ( ) Swelling; ( ) Bone
Deformity;
( ) Weakness; ( ) Atrophy; ( ) Contracture; ( )
Restriction of motion
Neuropsychiatric
( ) Syncope; ( ) Seizures; ( ) Weakness or Paralysis; ( )
Headache; ( ) Tremors; ( ) Memory Loss; ( )Depression; ( )
Delirium; ( ) Hallucination
Endocrine
( ) Weight Change: ( ) Heat or Cold Intolerance; ( ) Polyuria; ( )
Polydypsia;
( ) Polyphagia; ( ) Abnormal Growth
Hematologic
( ) Easy Bruisability ( ) Easy Fatigability; ( ) Pallor

PHYSICAL EXAMINATION

Integumentary
( ) pigmentation; ( ) lumps; ( ) sores; ( ) dryness; ( ) rash
; ( ) pruritus;
( ) change in hair & nails

GENERAL SURVEY
Consciousness:
_____________________________________________
Coherence:
________________________________________________
Attitude:
__________________________________________________
Nutritional development:
_____________________________________
Gross deformity:
____________________________________________
Posture:
___________________________________________________
Gait:
______________________________________________________
Ambulatory or Non-ambulatory:
_______________________________
Cardiac or resipiratory distress:
________________________________

Head and Neck

( ) Headache; ( ) Dizziness; ( ) syncope; ( ) Blurring of vision;
( ) Dilopia;
( ) Photophobia; ( ) Eye pain; ( ) Hearing
loss; ( ) Ear discharge; ( ) Ear pain;
( ) tinnitus; ( ) vertigo;
( ) Nasal obstruction; ( ) Epistaxis; ( ) Hoarseness;
()
Sore throat; () Disturbance of tastes

VITAL SIGNS:
o BP: ___________
o CR: ___________
o PR: ___________
o RR: ___________
o TEMP: ___________

Respiratory
( ) Cough; ( ) Dyspnea; ( ) Chest pain; ( ) Hemoptysis; ( ) Back
pain;
( ) Orthopnea; ( ) Trepopnea

INTEGUMENTARY:
Color: ___________
Texture: ___________
Moisture:
___________
Turgor: ___________
elasticity: ___________
Skin lesions:
________________________________________________
o Location:
____________________________________________
Hair:
______________________________________________________
Nails:
_____________________________________________________

GYNE history:
__________________________________________________________
Remarks:
__________________________________________________
REVIEW OF SYSTEMS
General
( ) weakness; ( ) weight change; ( ) Chills; ( ) fatigue; ( ) fever;
( ) sweats

Cardiovascular
( ) Chest pain; ( ) Palpitation; ( ) PND; ( ) Orthopnea; ( ) Easy
Fatigability;
( ) Shortness of breath
Gastro-Intestinal
( ) Poor appetite; ( ) Dysphagia; ( ) Odynophagia; ( ) Nausea;
( ) Vomiting;
( ) Hematemesis; ( ) Abdominal
enlargement;

SHERYLYN

MEDICAL EXAMINATION FORM3

HEENT
A. CRANIUM
Hair: _____________
Quantity: _____________ Color:
__________
Distribution of hair: _____________ Texture: _____________
Condtion of scalp: _____________
Size/shape: _____________ Symmetry: _____________
Deformities: _____________
Mass: _____________
Tenderness: _____________
Pulsations: _____________
B. FACE
Skin color_____________
Texture: _____________
Lesions:
___________________________________________________
Symmetry:
_________________________________________________
Facial expression:
___________________________________________
Facial movements:
__________________________________________
C. EYES
Eyebrow (color and distribution):
_______________________________
Eyelids and eyeballs:
_________________________________________
Conjunctiva (vascularity, edema, lesion, discharge):
__________________________________________________________
Sclera (vascularity):
__________________________________________
Cornea (transparency, lesions):
________________________________
Iris (color/contour):
__________________________________________
Pupils (size/shape, reaction to light, & accommodation):
__________________________________________________________
Lens (transparency):
_________________________________________
Visual acuity (near&distant):
___________________________________
Visual field (confrontation test):
________________________________
Evaluate the eyeball by palpation:
______________________________
Fundoscopy:
_______________________________________________
D. EARS
External ear (size/shape, symmetry, deformity, lesions):
__________________________________________________________
Tenderness:
________________________________________________
External auditory canal
o Patency: _______________
o Color of walls: _________________
o Discharge: _________________
o Foreigh body: _________________
Otoscopy:
__________________________________________________
Hearing test:
_______________________________________________
E. NOSE
Size/shape:
________________________________________________
Movement of ala nasi:
________________________________________
Vestibule: ________________
Patency: ________________

Secretions: ________________ bleeding points:

________________
Nasal septum (position/perforation):
____________________________
Paranasal sinuses:
o Frontal: ________________
o Maxillary: ________________
Tenderness: ________________
Transillumination: ________________
F. MOUTH & THROAT
Lips:
______________________________________________________
Buccal mucosa:
_____________________________________________
Tongue (size, position,mobility, mucosa, lesions):
__________________________________________________________
Teeth & gingiva:
____________________________________________
Palate:
____________________________________________________
Tonsils:
____________________________________________________
Post. Pharnygeal wall:
________________________________________
G. NECK
Skin:
______________________________________________________
Size/shape:
________________________________________________
Deformity:
_________________________________________________
Muscular development:
______________________________________
Postural alignment:
__________________________________________
Deviation:
_________________________________________________
ROM:
_____________________________________________________
Tenderness:
________________________________________________
Tone of muscles:
____________________________________________
Midline structures
o hyoid bone:
____________________________________________
o Trachea:
______________________________________________
o Thyroid:
_______________________________________________
o Lymph node:
___________________________________________
CHEST/LUNGS:
INSPECTION
Skin
o Color: ____________
Subcutaneous BV: ____________
o Hair pattern: ____________
lesions: ____________
o Muscle development:
__________________________________
Static dimension:
____________________________________________
Respiratory pattern:
_________________________________________
Chest expansion:
____________________________________________
PALPATION

SHERYLYN

MEDICAL EXAMINATION FORM4

Symmetrical areas (anterior lateral & posterior):
__________________________________________________________
Skin: ____________
Muscle: ____________ Ribs:
____________
Cartilages: ____________ Scapula: ____________ Spine:
_________
Symmetry of expansion:
______________________________________
Transmission of spoken words:
_________________________________
Fremitus:
__________________________________________________
PERCUSSION
Outline limits of resonance/dullness:
____________________________
AUSCULTATION:
Breath sounds (intensity, type, quality):
__________________________________________________________
Adventitious lung sounds:
_____________________________________
CARDIOVASCULAR
INSPECTION
A. HEART
Buldging/depression:
________________________________________
Precordial pulsations:
o Apical impulse:
_________________________________________
Location:
_________________________________________
Width:
___________________________________________
Extent:
___________________________________________
Adynamic/hperdynamic:
_____________________________
o Base epigastric:
_________________________________________
o Parasternal areas:
_______________________________________
B. NECK
Carotid pulsation:
___________________________________________
Any identified neck veins:
_____________________________________
Distention:
_________________________________________________
Estimated JVP:
______________________________________________
PALPATION
Apical impulse
o Location: _______________ Width: _________________
o Extent: _______________
Base epigastric
o Location: _______________ Width: _________________
o Extent: _______________
Parasternal areas
o Location: _______________ Width: _________________
o Extent: _______________
Thrills (location, timing):
______________________________________
Lifts:
______________________________________________________
Heaves:
___________________________________________________

ASCULTATION:
Rate: _______________
Rhythm: _______________
S1: _______________
S2: _______________
Physiological split of S2: _______________
Character of heart sounds:
____________________________________
Intensity of heart sounds:
_____________________________________
Extra heart sounds (S3 & S4):
__________________________________
Murmurs (timing/quality):
____________________________________
C. PERIPHERAL PULSES
Note for character, pulse, rate, rhythm, symmetry &
amplitude
Catorid:
___________________________________________________
Femoral:
___________________________________________________
Popliteal:
__________________________________________________
Radial/brachial:
_____________________________________________
Dorsalis pedis:
______________________________________________
Ascultate for presence or absence of carotid bruit:
_________________
ABDOMEN
INSPECTION
Size: ____________
Shape: ____________ Contour:
____________
Lesions: ____________ Superficial veins: ____________
Scars: ____________ Striae: ____________
Skin discolorations:
__________________________________________
Umbilicus:
_________________________________________________
Symmetry:
_________________________________________________
Movement:
________________________________________________
AUSCULTATION
Bowel sounds: __________ BS/min
Bruit
o Epigastric: ____________
o RUQ: ____________
o LUQ: ____________
PALPATION
Light palpation
o Tone:
________________________________________________
o Constistency:
__________________________________________
o Tenderness:
___________________________________________
o Superficial mass:
________________________________________
Deep palpation
o Tenderness (direct/rebound):
_____________________________
o Palpable organs (liver, spleen, kidneys):
_____________________
PERCUSSION
General tympanism:
_________________________________________

SHERYLYN

MEDICAL EXAMINATION FORM5

Liver dullness/span:
__________________________________________
Traubes space:
_____________________________________________
DIGITAL RECTAL
EXAM:____________________________________________
SPECIAL EXAM
Murphys sign: ____________
Psoas sign: ____________
Merkels sign: ____________
Obturator sign: ____________
Rovsings sign:
____________
Fluid wave: ____________
Shifting dullness: ____________
Puddle sign: ____________
Costovertebral angle tenderness: ____________
NEUROLOGICAL EXAM
A. CEREBRAL FUNCTION
Level of consciousness:
_____________________________________
Coherence:
______________________________________________
Ability to follow simple & complex commands:
__________________
Speech:
_________________________________________________
Intellectual performance
o Orientation:
___________________________________________
o Calculation:
____________________________________________
o Memory (remote, recent, immediate):
______________________________________________________
o General information:
____________________________________
o Abstract thinking:
_______________________________________
B. CRANIAL NERVES
CN 1
o Patency of nostrils:
______________________________________
o Non-volatile substance:
__________________________________
CN 2
o Visual acuity:
__________________________________________
o Confrontation test:
______________________________________
CN 2 & 3
o Papillary light reflex (direct & consensual):
___________________
CN 3, 4, 6
o EOM testing (any paralysis):
_______________________________
CN 5
o Sensory:
Pain/temp:
_______________________________________
Sensation:
________________________________________
Light touch:
_______________________________________
o Motor:

Masseter muscle (clench):

___________________________
CN 5 & 7
o Corneal reflex:
_________________________________________
CN 7
o Motor:
Upper facial muscle: ________________________________
Lower facial muscle:
________________________________
o Sensory:
Taste sensation:
____________________________________
Anterior 2/3 of tongue:
______________________________
CN 8
o Cochlear division:
Hearing evaluation:
_________________________________
Rinne/weber:
______________________________________
CN 9 & 10
o Gag reflex:
____________________________________________
o Position of uvula:
_______________________________________
o Pharyngeal wall movement:
_______________________________
CN 10
o Voice:
________________________________________________
o Nasal twang:
___________________________________________
CN 11
o Elevate shoulder against resistance:
________________________
o Resistance of head while laterally rotated:
___________________
CN 12
o Postion of tongue:
______________________________________
o Atrophy: ______________ In/Out movt of tongue:
__________
o Appearance:
___________________________________________
o Fasciculation:
__________________________________________
C. MOTOR TESTING
INSPECTION
Atrophy/Hypertrophy:
_____________________________________
Involuntary movements:
____________________________________
Fasciculations:
____________________________________________
MUSCLE TONE (spastic, rigid, hypotonic, normal):
_______________________________________________________________
_______________________________________________________________
MUSCLE STRENGTH (MMT grading, proximal & distal muscle
groups):

SHERYLYN

MEDICAL EXAMINATION FORM6

o
o
o
o

D. CEREBELLAR FUNCTION
Finger to nose (dysmetria):
__________________________________
Alternating supination & pronation
(dysdiadochokinesia): _________
Heel to shin test (dysmetria):
________________________________
Gait and stance (tandem walking):
____________________________
E. REFLEXES
Deep tendon:

Pathologic:
o Babinski:
______________________________________________
o Chaddock:
_____________________________________________
Superficial:
o Abdominal:
____________________________________________

F. SENSORY TESTING

Joint sense:
______________________________________________
Vibration sense:
__________________________________________
Sterognosia:
_____________________________________________
Rombergs test:
___________________________________________
G. MENINGEAL SIGN
Nuchal rigidity:
___________________________________________
Kernigs sign:
_____________________________________________
Brudzinski:
_______________________________________________
SPINE & EXTREMITIES
A. HAND & WRISTS
Inspection:
______________________________________________
Palpation:
_______________________________________________
o Tenderness: ___________
Swelling: ___________

Crepitus: ___________
Nodulation: ___________
Angulation: ___________
Symmetry: ___________
Mass: ___________
Deformities: ___________
Depression: ___________

Fingernails:
o Clubbing of nails:
_______________________________________
o Color of nailbeds:
_______________________________________
o Nail plate abnormalities:
_________________________________
ROM (flexion/extension PIPJ, DIPJ; abduction/adduction
MPJ; apposition thumb with the rest of fingers):
________________________________________________________
________________________________________________________
B. FOREARM
Palpate radius and ulna:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
ROM (pronation, supination):
________________________________
C. ELBOW
Palpate elbow:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
Landmarks: Olecranon process, medial epicondyle,
lateral epicondyle
ROM (flexion, extension, pronation, supination):
________________
Muscle circumference:
o Reference point: ________________
o Above elbow joint: ________________
o Below elbow joint: ________________
D. UPPER ARM
Palpate biceps & triceps muscle groups:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
E. SHOULDER JOINT
Landmarks: coracoids process, greater tuberosity of
humerus, acromion, scapula
ROM (abduction, adduction, elevation flexion, elevation
extension, medial rotation, lateral rotation):
____________________________
F. CERVICAL SPINE
Palpate cervical spine:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
ROM (flexion, lateral bending, extension):
_____________________
G. HIP JOINT
Palpate hip:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________

SHERYLYN

MEDICAL EXAMINATION FORM7

o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
Landmarks: iliac crest, iliac tubercle, greater
trochanter, pubic tubercle
ROM:
o Flexion:
_____________________________________________
o Adduction:
__________________________________________
o Passive hyperextension:
_______________________________
o Abduction of hip with leg extended:
______________________
o External & internal rotation of hip with knee in
flexion:
___________________________________________________
Test of hip joint:
o Anvil test:
___________________________________________
o Patricks test:
________________________________________
o Straight leg raising test:
________________________________
o Trendelenburg:
______________________________________
Knee joint:
o Deformities:
___________________________________________
o Cyst (anterior/posterior):
_________________________________
ROM (flexion, extension):
___________________________________
Muscle circumference:
o Reference point: _________________
o Above the knee joint: _________________
o Below the knee joint: _________________

H. ANKLE JOINT & FOOT

Palpate ankle joint:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
Palpate foot:
o Tenderness: ___________
Swelling: ___________
o Crepitus: ___________
Nodulation: ___________
o Angulation: ___________
Symmetry: ___________
o Mass: ___________
Deformities: ___________
o Depression: ___________
Landmarks: lateral malleolus, medial malleolus
ROM (dorsiflexion, plantar flexion, inversion, eversion):
________________________________________________________
Pedal deformities:
_________________________________________
Toes abnormalities:
_______________________________________
Cutaneous abnormalities:
___________________________________

SHERYLYN