HISTORY AND PHYSICAL EXAMINATION Current Medications:

Generic Brand Dosage Frequency Purpose

Date of Interview: Kremil S PRN
Time of History: Ranitidine 150mg? PRN
Informant: patient
Relationship to the Patient: ______________________
% Reliability: Immunizations:
 BCG  DPT  Polio  Hepa B ok
General Data: Others: Measles
Patient’s Name: Allergies:
Age: __ Sex: __ Marital Status: __ Food: none
Address: Medications: none
Birthday: __________ Birthplace: ___________ Pollen/Animals/Others: none
Nationality: ______ Religion: ____________ Childhood Illness:
Occupation: __________  rheumatic fever  polio
 chicken pox  measles
Date of Admission:  mumps
Time of Admission: others: ______________________________
No. of times admitted at CVMC: Adult Illness:
Illness Age Date of Diagnosis
Chief Complaint: Hypertension
Stroke
History of Present Illness: Renal
Onset: _______________________________ Asthma
Duration: _____________________________ TB
Frequency: _______________________ DM
Setting at which the Symptom Occurred: _______________________ Cardiac
_______________________________________________________ GI
Manifestations: ___________________________________________ STD
Location: ________________________________________ Others
Precipitating Factors: _______________________________
Quality: _________________________________________ Surgical Procedures:
Radiation: _______________________________________ Date: _______________________________
Severity: ________________________________________ Type of Operation: _____________________
Aggravating Factors: household chores Purpose: _____________________________
Alleviating Factors: ________________________________________ Previous Hospitalizations:
Previous Treatment for the Problem: __________________________ Date Cause Hospital Treatment
Associated Signs and Symptoms: _____________________________
________________________________________________________
Pertinent Positives and Negatives: ____________________________
________________________________________________________
Additional Notes: __________________________________________ Screening Tests:
________________________________________________________ Test Date Result
________________________________________________________ Tuberculin test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
Xray/CT Scan/MRI
Others

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
Past Medical History: ________ Abortions/Miscarriages
 ________ Living Children No. of occupants: ____________________
Date of Birth Sex Manner of Delivery Relationship to occupants: __________________________
______________________ ____________________ ________________________________________________
______________________ ____________________ Source of Drinking Water: deep well
______________________ ____________________ Garbage Disposal: _________________________________
Fecal Disposal: ___________________________________
OB Hx: G _ P_ (T-P-A-L) Pet/s: __________________________________________
G1: When _________, NSD or CS d/t _________, delivered by Personally gives bath to pets? Y/N
_________, where _________, M/F, weight _________, fetomaternal General State of neighborhood: _____________________
complications _____________________, present status __________.
Review of Systems:
Constitutional:
Family History:  Fever  Weight gain/loss
Family Age Health/ Age & Date of Cause of  Chills  Fatigue
Member Diseases Dx death Skin:
Father  Rashes  Itching
Mother  Lumps  Dryness
Others  Color Change  Changes in Nails
Hair:
 Baldness  Excess Hair
Head:
 Headache  Dizziness
Medical Problems for any blood-relative  Lightheadedness  Trauma
Relationship to Px Age & Date of Dx  Syncope  Tenderness
Cancer Eyes:
Hypertension  Pain  Redness
Diabetes  Double Vision  Blurred Vision
Tuberculosis  Use of Glass/Lenses  Photalgia
Heart Disease  Lacrimation
Stoke Ears:
Kidney Disease  Hearing Problem  Earache
Arthritis  Discharge (color/consistency) ____________
Blood Disorder  Tinnitus  Vertigo
Asthma Mother Nose and Sinuses:
Epilepsy  Epistaxis  Nasal stuffiness
Mental Disorder  Discharge (color/consistency): ____________
 Itching
Mouth and Throat:
Personal and Social History:  Use of dentures  Mouth sores
No. of years married: 35______  Bleeding Gums  Toothache
Health Status of Spouse: ______________  Sore throat  Hoarseness
No. of Children: 10 _______  Dysphagia
Health Status of Children: ___________________________________ Neck:
Highest Educational Attainment: ______________________________  Pain  Stiffness
Occupational History: _______________________________________  Lump
________________________________________________________ Breast:
________________________________________________________  Pain  Discharge
Occupational Hazards: _____________________________________  Lumps  Periodic Exam
Smoking Habits:
 non-smoker  smoker ex- Respiratory:
smoker  Cough  Sputum (color/quantity) ________
No. of sticks/packs per day: _________  Hemoptysis  Dysnea
Year started: ______ Year quitted: ______  Wheezing
Alcohol Consumption Cardiovascular:
 never  occasionally  Chest Pain  Palpitations
 daily  weekly  Orthopnea  Edema
Alcohol type: ___________________  Cyanosis  Paroxysmal Nocturnal Dyspnea
Amount Consumed: ______________  Easy Fatigability
Nutrition: Gastrointestinal:
No. of meals per day: ________  Loss of appetite  Nausea
Food preferences: ___________________  Vomiting  Hematemesis
Coffee/tea/soda intake: _______________  Abdominal pain  Diarrhea
Nutrient Supplement:: ________________  Hematochezia  Excessive belching/passing of gas
OTC: _______________________ Renal:
Prohibited Drugs: _____________  Dysuria  Polyuria
Substance Abuse: _____________  Nocturia  Gross Hematuria
Exercise: ___________________________________  Incontinence  Urinary Retention
Regularity of Sleep: 5 hours ___________________________  Urinary Urgency  Tea-Colored Urine
Habits/hobbies: ______________________________ In Males:
Sources of Stress: ___________________________  Reduced caliber of force of stream
Coping Strategies: ___________________________  Hesitancy
Living Conditions:  Dribbling
No. of years in current residence: _35 years______ Genitalia:
Previous place of residence: ____________  Pain  Swelling
___________________________________  Discharge (characteristics): ________________
Type of residence: ___________________  Ulcers  Itching
No. of rooms: _______________________ Peripheral vascular:
 Leg cramps  Varicose veins
Muskuloskeletal: Blood vessels: _________________
 Muscle weakness  Stiffness
 Backache  Joint swelling Ears:
 Muscle pain  Join Pain Symmetry: _______________
Neurologic:  Swelling: ______________________________
 Paralysis  Numbness  Redness: ______________________________
 Tremors  Seizures  Discharge: ______________________________
 Memory Loss  Tenderness: _____________________________
Hematologic:  Hearing Impairments: _______________________
 Easy bruising  Bleeding  Presence of Hearing Aid: _____________________
 Pallor Weber Test: ______________________________
Endocrine Rinne Test: (R) AC __________ BC ___________
 Polydypsia  Polyphagia (L) AC __________ BC ___________
 Heat/cold intolerance  Excessive sweating
Psychiatric: Nose:
 Nervousness  Depression Symmetry: ___________________________
 Anxiety  Hallucinations Frontal, maxillary sinus tenderness: ____________________
Obstruction: __________________________
PHYSICAL EXAMINATION Congestion: __________________________
Lesions: _____________________________
General Survey: Exudates: ____________________________
Mood: ______________ Inflammation: _________________________
Distress/ Unusual Position: _____________
Cooperative/ Non-cooperative Throat:
Irritable/agitated/pleasant Lips: _____________________
Coherent: _________ Teeth/dentures: _______________________
Oriented to time and space: _______ Gums: _______________________________
Personal Hygiene: _______________ Tongue: _____________________________
Level of Consciousness: _______________ Pharynx:
Height: ____________  Lesions: ______________  Erythema: _____________
Weight: ____________  Exudates: _____________ Tonsillar Size: _________
BMI: ______________
Neck:
Vital Signs: Symmetry: _________________________
Temperature: ________  Oral  Axillary  Rectal Limitation of ROM: __________________
Respiration: _________  Normal  Labored Tenderness: _________________________
Pulse: _____________  Regular  R. Irreg.  Irr. irreg. JVD: ______________________________
Blood Pressure: _______  Lying  Sitting  Standing Lymph nodes: ________________________
Size: _____________
Head: Mobility: ___________
Trauma: ________________________________ Tenderness: _____________
Size: ______________ Shape: _____________ Borders: ________________
Tenderness: __________________________________ Consistency: _____________
Condition of hair and scalp: _______________________________ Thyroid cartilage: _____________ Cricoid cartilage: ______________
Symmetry: ___________________________ Thyroid gland: ________________
Masses: _____________________________
Chest and Lungs
Eyes: Inspection
Visual acuity: Comfort and Breathing Pattern: _____________________
Far: (R) ________ (L) ________ Shape of the Chest: ______________________________
Near: (R) ________ (L) ________ Chest Movement: ________________________________
Visual Fields (H test): ___________________  Use of Accessory Muscles of Breathing: ______________
Accommodation: _______________________  Deformities of Asymmetry: _________________________
Test of confrontation: ___________________  A/N Retraction of Interspaces on Inspiration: ___________
Conjunctiva:  Impairment of Respiratory Movement: ________________
Color: ____________________________ Color of Patient (Lips & Nail Bed): ___________________
Discharge: ________________________ Palpation
Sclerae:  Tender Areas: ___________________________________
Color: ____________________________ Respiratory Expansion (10th rib): Symmetry  Yes  No
Discharge: ________________________ Tactile Fremitus: Symmetry 
Cornea: Increased Decreased Absent 
Clarity: ___________________________ Percussion: ____________________________________
Corneal Arcus: _____________________ Auscultation
Lids: ______________ Iris: ________________ Breath Sounds: _________________________________
Position of eyes in orbits: ______________________________  Bronchophony  Whispered Petoriloquy
Pupil:  Egophony

Size: (R) __________ (L) ___________ Heart:

Shape: ____________ Symmetry: ______________ Inspection
Accommodation: _______________ Precordial bulge or heave: __________________
Light reflex test (PERLA): ________________ PMI: __________________________
EOM: ________________________ Palpation
Visual Field: ____________________________ PMI: __________________________
Direct Reaction: ____________ Consensual Reaction: ____________ Thrill: _____
Fundoscopic Location: _________________
Red orange reflex: ______________ Timing in Cardiac Cycle (S/D): ______________
Disc: ________________________ Mode of Extension/Transmission: ____________
Macula: _____________________  Friction Rub: ___________________
Percussion: Cardiac Borders Orientation
Right (cm) ICS/MSL Left (cm) Name:  Season  Date  Day  Month  Year
5th Name:  Hospital  Floor  Town  State  Country
4th Level of consciousness:
3rd B. Speech (Normal, dysphasia, dysarthria, dysphonia)
- 2nd C. Language
Auscultation Name:  Pencil  Watch
S1 (M-loud, T-split): ___________________ Repeat: “ No ifs  ands  or buts”
S2 (A,P-loud, P-split I): ___________________ D. General Knowledge
S3: _________________________ Knowledge of current events, vocabulary
Murmurs/Accessory Heart Sounds: (Historical events, 5 last presidents, 5 largest cities)
Location: __________________ Timing: _______________ E. Memory
Quality: ___________________ Pitch: ________________ Immediate, recent, remote
Intensity: __________________ Radiation: _____________ F. Registration (Retention and recall)
Identify:  Object 1  Object 2  Object 3
Breast: Attention and Calculation
Symmetry: _____________ (100-7…):  93  86  79  72  65
 Dimpling/Skin Retraction: _____________________ Recall
 Swelling: ____________________ Recall:  Object 1  Object 2  Object 3
 Discoloration (Skin changes): _________________ G. Reasoning
 Orange Peel Effect: _________________ Judgment, Insight, abstraction (interpretation of proverbs)
Position and Characteristic of Nipple: _________________ H. Object recognition
 Gynecomastia (Male): _________________ Agnosia (Visual, tactile, auditory, autotopagnosia, anosognosia)
 Mass: Praxis (Ideomotor, Ideational)
Location: _____________________________ Perception (Delusion, Hallucination, illusion, astereognosis,
Size: ___________ Consistency: _________________ agraphestesia)
Tenderness: ______________ Mobility: _____________ I. Follows Command
Borders: _________________  Take this paper.  Fold it in half.  Place it on the table.
 Obey written command.
Abdomen:  Write a sentence.
Inspection  Copy a design.
 Irregular Contours: ____________ Scars Total: _____
 Discoloration: ________________
 Bulges: _____________________ Cranial Nerve Examination
Shape: _____________________ CN I
 Striae: ______________________  Identify odorant
Distance of umbilicus from xiphoid process: __________ CN II
Abdominal Girth: __________________ Visual acuity: ________ Visual field: _________
Auscultation Fundoscopy: ____________________________________________
Bowel Sounds: Frequency: ___________ Character: ____________ CN III, IV, VI
 Bruit: ___________________ Size and Shape of Pupil: __________________
 Venous Hum: ______________  Light Reaction  Accommodation
 Friction Rub: _______________ EOM:
Percussion  Paresis  Nystagmus
Liver Span: _______________ Normal: 6-12 cm in (R)MCL  Saccades  Oculomotor Ataxia
Splenic Dullness: ______________  Diplopia  Other _____________
Other Areas of Dullness: _______________ CN V
Special Tests  Ophthalmic  Maxillary
 Rebound Tenderness: Rovsing’s, Blumberg  Mandibular  Corneal Reflex
 Costovertebral Tenderness  Jaw Clench
 Shifting Dullness CN VII
 Psoas Sign  Eyebrow Elevation  Forehead Wrinkling
 Murphy’s Sign  Eye Closure  Smiling
 Cheek Puffing
Male Genitalia: CN VIII
 Penile Lesions: _______________  Hear finger rub or whispered voice
 Scrotal Swelling: _______________________ Rinne: ____________ Weber: ____________
Testicles CN IX, X
Size: ________  Tenderness: ___________ Palate and Uvula: _____________
 Masses: ______________  Gag Reflex
 Varicocoele: _________________ CN XI
 Hernia: ________________  Shoulder Shrug (against resistance)
Transillumination: ________________  Head Rotation (against resistance)
CN XII (Tongue)
Extremities:  Atrophy  Fasciculation
Amputation Visible joint swelling Position with protrusion: _________
 Deformities Limitation of ROM Strength: __________
Tenderness Redness
Warmth Edema Motor Examination
 Involuntary Movements
Capillary refill: ______________  Symmetry
Peripheral pulses: ___________  Atrophy
 Gait
 Paresis
NEUROLOGICAL EXAMINATION  Paralysis
 Spasticity
Mental Status Examination  Rigidity
A. Awareness  Flaccidity
  Clonus
 Carpopedal Spasm
 Tics
 Tremors
 Athetosis
 Others

Tone
Description: ____________________________
 Flaccidity
 Spasticity

Muscle Strength

(R) (L)
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
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

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