Source: _____________________________________________ Date and Time: _______________________

Reliability: __________% Ward: ______________________________

GENERAL DATA
Name: ___________________________________________________________________________________________________
Birthdate: _______________ Age: _____ Gender: M F Nationality: Filipino Others: __________ Religion: __________
Relationship Status: Single Married Widowed Others: _________ Occupation: _______________
Current Address: __________________________________________________________________________________________
Date of Admission: __________ Time of Admission: __________ Hospital Admitted: __________________________ 1st time
Chief Complaint(s):_________________________________________________________________________________________
_________________________________________________________________________________________________________

PAST MEDICAL HISTORY

Childhood Illnesses:
Immunization Status:
Adult Illnesses:
141/1
Measles
BCG
Mumps
MMR OPV
Chicken Pox Rubella
Influenza I Varicella
Others: _________________________________________
Herpes zosterrHBV HPV
Others: ____________________________________________________________________________________
Others: _____________

:
Date of Medications/ Compliance
None Dosage Other Pertinent Data
Diagnosis Maintenance Good Bad
Highest: Usual:
Hypertension Controlled? Other s/s:

Highest: Usual:
Diabetes Controlled? Other s/s:

Last attack:
Asthma Frequency of attack?

Arthritis

Previous hospitalizations (medical, surgical, psychiatric):

Hospital Duration Discharge Status
Date (Physician and Diagnosis of Treatment Improved Otherwise
specialization) Admission

Past Illnesses Date Interventions

Food and Drug Allergies: ____________________________________________________________________________________

________________________________________________________________________________________________________

OBSTETRIC HISTORY
OB Score: G___ T___ P____ A___ L___ LMP: __________________ PMP: __________________
Age of First Pregnancy: _____ Previous CS History of dystocia Regular PNC Natal infections: ______________
Previous Pregnancies: GDM: __________ Hypertension: __________ Others: ______________________________
Menstruation: Age: _____ Regular Irregular Duration: _____ Days cycle: _____ Pads per day: _____
Symptoms: Dysmenorrhea Amenorrhea Unusual discharges: ______________ Others: __________________
Present: Not pregnant Pregnant AOG: __________
Prenatal History (check-up, vitamins, tetanus shots): ______________________________________________________________
_________________________________________________________________________________________________________

Mode of
Year Status Weight Gender Condition Complications Breastfeeding
Delivery

G1

G2

G3

G4

G5

G6

Sexual contact: 1st: _____ No. of partners: _____ with male: _____ with female _____ Dypareunia
Other problems: ________________________________________
Risky Sexual Behaviors: No Yes: ____________________
Birth Control: None Condom OCPs Diaphragm IUD Surgical(year): _____________ Others: _________________
History of STI: None Yes, specify: ______________________

PERSONAL AND SOCIAL HISTORY

/
Educational Background: None Elementary High School College Others: _______________________________________
Living Condition: Concrete Lightweight: _________ No. of people in house:3
_____
Relationship to people living in house: __________________ Anyone sick?, No Yes: ________
Well-ventilated(Congested No. of rooms: ____
Role of Patient in Family: _______________ Rank of Patient in Family: _______________ Monthly income: ____________ min .

Work History: _______________

Sleep: Sleeps at: __________ Wakes up at: __________ Hours of sleep: __________
wage
Usual Food Preferences:'Pork Beef 'Fish 'Vegetables Sweet Salty Others: ________________________________
Food source: ______________________________ Preparation: ____________________________________________________
Usual Fluid/Drink Preferences: Water: _____ glasses Coffee: _________ cups Soft drinks: _________ bottles
Others: ________
Water Source: For drinking: ________________________________ Cooking and others: ________________________________
Voiding: Regular Polyuria Oliguria Anuria Incontinence Nocturia Hematuria Dysuria Urgency Others: _________
Volume: __________
Defecation: Days per week: _____ Regular Constipation Diarrhea Bloody Others: ____________________
Supplements, vitamins: _____________________________________________________________________________________
Routine check-up BSA
Stressors: ________________________________________________________________________________________________
Source of Support: _________________________________________________________________________________________
Coping style: Eating Drinking Exercise Others: _____________________________________________________________
ADLs (usual routine, include sleep and rest): Sedentary

Time Activity Time Activity

Exercise: Type: _______________________________________ Minutes per day: ___________ Minutes per week: ___________
Recent Travel History: None Specify (when, where, how long): ___________________________________________________
Tobacco Use: Age: _____ No. of sticks per day: _____ Pack years: _____
Alcohol Use: Age: _____ No. of bottles: _____ Frequency: __________ Preference: Rhum Beer Others________________
Illegal Drug Use: Never Yes, age: _____ Forms: __________ Stopped, when: __________
Sexual contact: No Yes, 1st: _____ No. of partners: _____ with male: _____ with female _____ Dypareunia
Other problems: ________________________________________
Risky Sexual Behaviors: No Yes: ____________________
Contraceptives: None Condom OCPs Diaphragm IUD Others: ______________________________

FAMILY HISTORY
Father: Alive Dead : at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: __________
Mother: Alive Dead : at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: __________
Grandfather: Alive Dead : at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: __________
Grandmother: Alive Dead : at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: __________
Siblings: M/F Alive Dead : at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: ___________
M/F Alive Dead :at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: ___________
M/F Alive Dead :at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: ___________
Children: M/F Alive Dead :at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: ___________
M/F Alive Dead :at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: ___________
M/ F Alive Dead :at age of ___ Healthy DM HPN Stroke Asthma Cancer: _______ Others: __________

HISTORY OF PRESENT ILLNESS

Days PTA Conditions Medications

 GENERAL SURVEY
Alert Drowsy Coherent Tachypneic Dyspneic Febrile Stuporous
Awake Confused Cooperative Dyspneic Coma In Pain Responsive
Respiratory distress
Attachments (e.g. IV line, O2, others): __________________________________________________________________________

VITAL SIGNS
BP: L arm: __________ mmHg R arm: __________ mmHg PR: _____ bpm RR: _____ cpm Temp: _____ °C/axilla
Height: _____ cm Weight: _____ kg BMI: _____

SKIN AND NAILS

Pale
I
Skin: Color: ________ Moist Dry Rough Smooth Scaly Jaundice Masses Lumps Bruises Good skin turgor
Lesions(flat/raised/no/size/shape/color/texture/location/): _________________________________________________________
Skin Hair:-Well distributed Fine Coarse
Nails: Cyanotic Finger Clubbing Lesions: __________________________________________________________________
-
HEAD pale
Normocephalic Deformed
Hair: Black Brown Gray/White Others __________
Well distributed Fine Coarse Moist Dry Hair loss: _________ Dandruff Lice infestation Lumps Lesions ______
Tenderness on palpation
CN V: Intact facial sensation (pain, temperature)-Clench teeth
CN VII: Face symmetric-Facial expression intact – able to smile, wrinkle forehead, puff cheek

EYES
-Symmetric
Eyebrows: ____________________ Eyelashes: ____________________
-
Eyelids: Normal Inflammation
Palpebral Fissure: Distance: ____ mm Narrowed (lid lag) Widened Exophthalmos
Periorbital edema: No Yes, ___________
✓ Pale
Conjunctiva: Pinkish Edema Hemorrhage Dry (xerophthalmia) Pterygium Conjunctiva

I
Sclera: White Icteric Blue Others ____________________
Cornea: Transparent Moist Dry Inflammation Lacerations Arcus senilis Arcus juvenilis
Corneal Reflex (CN V and VII):-Positive Delayed
Lens: Transparent Opaque Red orange reflex (ophthalmoscope):,Positive Negative
dark brown
1
Iris: Clearly defined Color: _____________
Pupils: Equally round Not equally round Size: _____ mm (normal: 3-5 mm)
Pupillary Light Reflex (CN II and III): Direct and Consensual Reaction to Eye

Direct Consensual

Left Eye t t
Right Eye t t
Accommodation Reflex: Eyeball:/Convergence No convergence Pupil constriction: IPresent Absent
CN II:
Visual Acuity: can read _____________ at _____ ft away each eye
Visual Field: intact / defect on __________ field __________ eye by confrontation test
EOM by Finger Following Test (50 cm away) (CN III, IV, VI):/Full range of motion Delayed: ______________ Absent:
IOP (digital palpation test): ISoft Hard Very Soft Equal
EARS
✓Symmetric Discharges ______________________________ Inflammation
.

Gross Deformities: IAbsent Present: ______________________

Tug test: Tenderness Others ____________________
Otoscopy:
Tympanic membrane: 'Intact'Grayish pearly white'Good cone of light Position: _____________
Discharges, color__________ consistency__________ odor__________

:
Ear Canal: Normal Discharges, color__________ consistency__________ odor__________
Slightly concave Others____________________ Tenderness Recoils
CN VIII: Hearing acuity – both ears able to hear whispered voice at __________ ft
Weber’s Test: Not lateralized Lateralized to: ____________ ear
Rinne’s Test: AC > BC BC ³ AC AC > BC

NOSE
Alar flaring Deformities: ____________________
Nasal septum: Intact Midline Perforations Deviations Inflammation
pale
Nasal mucosa: color____________________
dry Moisture __________
Lesions
Discharges, color__________ consistency__________ odor__________
Polyps Swelling

Turbinates:/No congestion Congestion

Paranasal sinuses (Transillumination): ITranslucent (clear) Congestion Tenderness
CN /
I: Intact (able to identify coffee/soap) Not intact: L / R

MOUTH AND PHARYNX

pale
Lips: color__________ dry
Moisture__________ Lesion__________1 Cracks Scales
pale
Oral Mucosa: color__________ Ulcers Patches

pale pink
Gums: color __________ Bleeding Swelling
Teeth:, Complete Incomplete, #__________ Dentures Caries

pink
Tongue: color__________
CN XII:/Tongue midline on protrusion
Moisture__________ Lesion__________ Exudates: ____________
Tongue deviated on protrusion, side__________ Wrinkling Fasciculations
CN VII: sweet salty sour
Uvula:/Midline Deviated: __________ mobility__________

ping
Tonsils: color__________ Normal Hyperemic: ___________________ Exudates
Palate: Soft, color: __________ Hard, color: __________
pole
Pharyngeal Mucosa: color: __________ exudates: __________ Swelling
CN V: Jaw at midline on protrusion Jaw deviated on protrusion, side: __________
CN IX and X: Gag reflex: Positive Negative

NECK
lSymmetric
Symmetry: Asymmetric
Lesions Masses Bruising Supple (flexion, extension, sideways) Tenderness on palpation Palpable masses
Pulsations (blood vessels): Absent Present (expansile carotid aneurysms) Bounding Bruits
JVP: __________ cm above sternal angle w/ HOB @ __________ °
Lymph Nodes: Tenderness: l Nontender Tender: ________________ Palpation: Nonpalpable Palpable: _______________
Trachea:lMidline Deviated: ___________
Thyroid Gland: Mobile upon swallowing Tender on Palpation Not palpable Bruit
CN XI: /Rise shoulderseRotate head to the left and right sShoulder drop
/Able to swallow

ANTERIOR CHEST AND LUNGS

Symmetry:-Symmetric Asymmetric
Shape:-Normal Others __________
Lesions/Masses Bruising Retractions Use of accessory muscles Bony deformities
Palpation:
 Chest Expansion: Equal Delayed: L / R
Tactile Fremitus:=Equal Increased L / R Diminished L / R

÷
Percussion: Resonant Dull: ____________ Hyperresonance Others: ____________________
Auscultation: Vesicular Rales/crackles Wheezes and rhonchi: _____________ Others: ____________________

POSTERIOR CHEST AND LUNGS

Symmetry: Symmetric Asymmetric
Shape: Normal Others __________
Lesions/Masses Bruising Retractions Use of accessory muscles Bony deformities
Palpation:
Chest Expansion:
Tactile Fremitus: = Equal
Equal
Delayed: L / R
Increased L / R Diminished L / R
Percussion:
Auscultation:
= Resonant
Vesicular
Dull: ____________
Rales/crackles
Hyperresonance Others: ____________________
Wheezes and rhonchi: _____________ Friction rubs Others: _________________
Egophony: Normal (E sound) Abnormal (A sound with nasal bleating quality)
Bronchopony: Normal (muffled and indistinct) Abnormal (louder voice sounds)
Whisper Pectoriloquy: Normal (faints and indistinct) Abnormal (loud and clear)

BREAST
Skin: _______________ Color: ______________
Breasts: Symmetric Asymmetric Others: _______________
Breast Contours: Mass/Lesions Bruises Dimpling Flattening Edema/thickening (orange peel skin)
Nipples: Symmetric Asymmetric Nipple Retraction Rashes Ulcerations Size: __________ Shape: __________
Nipple Discharges: No Yes, color: _______________ Consistency: _______________ Odor: _______________
Breast Tissue: Consistency: _______________ Tenderness: __________
Breast Tissue Nodules: No Yes, location: __________ Size: __________ Shape: __________ Consistency: __________
Delimitation: __________ Tenderness: __________ Mobility: __________
Nipple Discharges upon Pinching: No Yes, color: ________ Consistency: ________ Quantity: ________ Odor: ________

HEART
PMI:-Clearly visible Barely visible
Forceful Diameter: __________ cm (£2.5 cm)
Not visible Palpable at R / L 3rd
I
4th 5th ICS __________ cm from MSL Brisk

Palpation: Thrills Heaves and lifts

CAD: 3rd ICS = __________ cm from MSL (4-5cm)
4th ICS = __________ cm from MSL (6-7 cm)
5th ICS = __________ cm from MSL (8-10 cm)
6th ICS = __________ cm from MSL (if 5th > 10 cm)
S1 and S2: Distinct Not distinct Gallops -

HR: __________ bpm

Murmurs: None Present, timing__________ loc. of max. intensity__________ radiation/transmission__________
intensity__________ pitch__________ quality__________
Grade 1 Very faint, heard only after listener has “tuned in” ; may not be heard in all positions
Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest
Grade 3 Moderately loud
Grade 4 Loud, with palpable thrill
Grade 5 Very loud, with thrill. May be heard when the stethoscope is partly off the chest
Grade 6 Very loud, with thrill. May be head with stethoscope entirely off the chest

BACK
Bony Deformities: I None Present Kyphosis Lordosis Scoliosis Lesions Bruises Palpable lymph node
Kidney Punch Test: Costovertebral angle tenderness
ABDOMEN
Symmetry:ISymmetric Asymmetric Shape: __________
Skin: Warm Cool /Clammy Bruises Erythema Jaundice Scars, location_______ Dilated veins Rashes/ecchymosis
Umbilicus: Shape: __________ Location: __________ TO
"
Contour: Flat Rounded Protuberant
Bowel Movements: Peristalsis Bulges
Scaphoid Local bulges Visible organ/masses: ________ Increased pulsations

Bowel Sounds: Normoactive (5-34 gargles/min) IHyperperistalsis Hypoperistalsis Bruits: aorta / iliac arteries / femoral
arteries Friction rubs: liver / spleen
Percussion: /Tympanitic: _________________ Dullness: _____________________

:
Fluid wave: Negative Positive
Shifting dullness: Border stays relatively constant Shift of dullness: __________ Shift of tympany: __________
Liver Dullness:
MSL: _____ cm (4-8 cm)
Right MCL: _____ cm (6-12 cm)
Palpation: Masses, location: ___________ Size: __________ Shape: __________ Consistency: __________ Tenderness:
_____________ Pulsations: __________ Mobility with respiration: __________
Liver: Normal Enlarged Nodular/nontender Others: _________________________________
Spleen: Not palpable Palpable
Kidneys: Right kidneys: Palpable Not palpable Left kidneys: Palpable Not palpable
Murphy sign: Negative (no pain) Positive (sharp increase in tenderness with inspiratory effort)
Rovsing sign: Negative (no pain) Positive (pain in RLQ during left-sided pressure)
Direct tenderness: Negative (no pain) Positive (painful)
Rebound tenderness: upon sudden removal of pressure: No severe pain Severe pain
Abdominal Reflex (above: T8-10, below: T10-12): Positive: _____ Negative
Psoas Sign: Negative (no pain) Positive (increased abdominal pain on flexion/extension)
Obturator Sign: Negative (no pain) Positive (right hypogastric pain)

UPPER EXTREMITIES
Symmetry:-Symmetric Asymmetric
Rashes Deformities

:
Limitation of movements: None Yes: flexion extension abduction adduction internal and external rotation
Edema: Non-pitting Pitting
1+ Mild pitting, slight indentation, no perceptible swelling of leg 0-15 secs, ≤ 2 mm
2+ Moderate pitting, indentation subsides rapidly 16-30 secs, 2–4 mm
3+ Deep pitting, indented for a short time, leg looks swollen 31–80 secs, 4–8 mm
4+ Very deep pitting, indented lasts a long time, leg is very swollen > 60 secs, 6-8 mm
Muscles: Atrophy Fasciculations Wasting Tenderness Swelling Abnormal positioning
Joints: Crepitation Pain Swelling
Capillary Refill Time: < 2 secs >2 secs
Peripheral Pulses: __________
Nail clubbing Cyanosis Reflexes Intact pain and temperature sensation
Deltoid Muscle Response: Positive Negative
Pronator Drift Test: Positive Negative
Hand Grip Test: Positive Negative
Muscle Strength: L _____/5 R_____/5

LOWER EXTREMITIES
Symmetry: Symmetric Asymmetric
Rashes Deformities
Limitation of movements: None Yes: flexion extension abduction adduction external rotation internal rotation
Edema: Non-pitting Pitting
 1+ Mild pitting, slight indentation, no perceptible swelling of leg 0-15 secs, ≤ 2 mm
2+ Moderate pitting, indentation subsides rapidly 16-30 secs, 2–4 mm
3+ Deep pitting, indented for a short time, leg looks swollen 31–80 secs, 4–8 mm
4+ Very deep pitting, indented lasts a long time, leg is very swollen > 60 secs, 6-8 mm
Muscles: Atrophy Fasciculations Wasting Tenderness
Joints: Crepitation Pain Swelling
Capillary Refill Time: < 2 secs >2 secs
Peripheral Pulses: __________
Nail clubbing Cyanosis Reflexes Intact pain and temperature sensation
Tandem Walk Heel to Toe: Positive Negative
Walk on Toes then Heels: Positive Negative
Hop in Place: Normal Weak
Shallow Knee Bend: Can bend and rise Cannot bend and rise
Rise from Squat: Positive Negative
Muscle Strength: L _____/5 R_____/5

NEUROLOGICAL EXAM
Cerebral:
irritable
General behavior and mood ______________________________

:
orientated to time and place long-term memory short-term memory
agnosia (objects) aphasia (language) apraxia (movement)
able to calculate abstract reasoning GCS E(4)__ M(6)__ V(5)__

Cranial Nerves:
I Sense of smell intact

Visual acuity good, both pupils reactive to light - direct and consensual,
II, III
visual field intact by confrontation test

III, IV, VI Extraocular muscles intact by Finger Following Test

(+) corneal reflex, facial sensations intact, muscles of mastication strong, smooth jaw movements
V

VII Face symmetrical, taste in anterior 2/3 of tongue intact, facial movements good

Able to hear whispered, spoken, loud voice at ___ ft

VIII

(+) gag reflex, uvula and soft palate at midline, well-modulated voice, posterior pharynx constricts upon
IX, X
prolonged “ahh”

XI Can shrug shoulders and rotate head against resistance

XII Tongue at midline on protrusion

Cerebellar:
Finger-to-nose test: Positive Negative
Rapid rhythmic alternating movements: Positive Negative
Heel-to-shin test: Positive Negative
Figure of 8 test: Positive Negative
Tandem walking: Positive Negative

Sensory:
Touch: Positive Negative
 Pain: Positive Negative
Vibration sense: Normal Diminished Loss
Stereognosis: Positive Negative
Texture discrimination: Rough: Positive Negative
Smooth: Positive Negative
Romberg’s test: Negative (swaying or falling with both eyes open and closed)
Positive (marked with swaying or falling with eyes closed)

Motor:
Muscle tone: Normal Hypotonia Hypertonia
Muscle substance: Atrophy Fasciculations Wasting Tenderness
Gait: Positive Negative
Involuntary movements: Positive Negative
Coordination of movements: Positive Negative
Tandem walk walk on toes walk on heels Romberg’s Test
Muscle tone Full ROM Limited ROM
Muscle strength:

0 No muscle contraction detected

1 Barely detectable, flicker or trace
2 Gross movements but not against gravity – severe weakness
3 Gross movements against gravity – moderate weakness
4 Gross movements against slight resistance – mild weakness
5 Gross movements against full resistance – full strength

REFLEXES:
_____ Biceps (C5, 6) _____ Abdominal (above: T8-10, below: T10-12) _____ Achilles Tendon (S2,3,4)
_____ Triceps (C6,7) _____ Patellar (L5, S1) _____ Plantar (L5, S1)
_____ Supinator/Brachioradialis (C5,6) _____ Ankle clonus _____ Babinski’s Sign

4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 Reflex absent