HEALTH HISTORY GUIDE

Date of Interview: _________________________________

Time of History: ___________________________________ ___________ PTA, __________
Informant: _______________________________________ P
Relationship to Patient: _____________________________ Q
% Reliability: _____________________________________ R
S
T
General Information Consultation
I. GENERAL DATA Medications
Outcome
Patient’s Name: __________________________________
Age: ________________ Gender: ___________________ ___________ PTA, __________
Marital Status: ___________________________________ P
Address: ________________________________________
Q
Birthday: _________________ Birthplace: _____________
R
Nationality: _______________ Religion: _______________
S
Occupation: ______________________________________
T
Date of Admission: ________________________________ Consultation
Time of Admission: ________________________________ Medications
No. of Times Admitted at OM: ________________________ Outcome

___________ PTA, __________

P
CHIEF COMPLAINT(CC): _______________________ Q
R
HISTORY OF PRESENT ILLNESS S
Provocative: ____________________________________ T
Palliative: ______________________________________ Consultation
Quality: _______________________________________ Medications
Radiation: _____________________________________ Outcome
Severity: ______________________________________
Timing II. PAST MEDICAL HISTORY
 Onset: ______________________________
 Duration: ____________________________ Childhood Illness:
 Frequency: ___________________________  chickenpox  measles
Pertinent Positives: ______________________________  mumps  rheumatic fever
Pertinent Negatives: _____________________________  polio  other: ______________
Narration of CC from the time it was first felt up to the current admission:
Adult Illness
__________ PTA, __________ Diseases Age when Diagnosed Medication/s taken
P (Dose, Frequency)
Q Hypertension
R Diabetes Mellitus
S Stroke
T Asthma
Consultation Renal
Medications TB
Outcome Other:

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
 Date of Gender Mode of Delivery
Delivery
Other Medications taking:
Medication/s Indication Dosage and Frequency
(Generic and Brand
Name)

FAMILY HISTORY

Immunizations:
Family Member Age Healthy/Diseases Date of Dx
 BCG  Hepa B
 DPT  other: ______________
 polio

Allergies:
Food: _______________________________
Medications: __________________________ Death in the Family
Others: ______________________________
Family Member Age Cause of Death Date of
Death
Surgical Procedures:
Procedure Indication Date

Previous Hospitalizations:
Date Cause Hospital Management Medical Conditions in the Family

Family Member Relationship Age and Date of Dx

Cancer
Hypertension
Screening Tests:
DM
Test Date Result
TB
Pap Smear
Heart Disease
Mammogram
Kidney Disease
Xray
Asthma
Others:
Epilepsy
Mental Disorder
Obstetric History:
Other:
LMP:
Menarche:_______  Regular  Irregular
Duration of Period: _________________ VI.PERSONAL AND SOCIAL HISTORY
No. of pad consumed: _______________
Age of Menopause: _________________ No. of years married: _____________________
Bleeding? ________________________ Health condition of spouse: ________________
Birth Control Method: _______________ Highest educational attainment: _____________
Habits:
Gravida: _____________ Parity: ______________ Sleeping patterns: _____________________
Term: _______________ Exercise: ____________________________
Preterm: ____________ Coffee: No. of cups/day_______
Abortion: ____________ Living: ______________ Smoking: Packs/day: _______ Since: ______ Stops: ______
Other vices: __________________________
Occupation:
Past: _______________________________

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
 Present: ____________________________ ( ) swelling in calves, legs, or feet; ( ) unusual color,
Occupational Hazards: _________________ ( ) Change in fingertips or toes during cold weather, ( ) swelling with redness, ( ) tenderness
Duration of work: ____________________
Type of Residence GENITAL: ( ) pain, ( ) discharge, ( ) swelling
No. of Rooms and occupants: __________ Male: ( ) Hernias, ( ) discharge from penis, ( ) sores on the penis, testicular pain,
Water Source: ______________________ ( ) testicular masses, ( ) scrotal pain, ( ) scrotal swelling,
Fecal Disposal: _____________________ ( ) history of sexually transmitted infections and their treatments: __________
Pets: _________________________________ ( ) Sexual habits: __________ ( ) birth control methods: ( ) condom use,
Female: ( ) dysmenorrheaAge at menopause, ( ) Vaginal discharge, ( ) itching, ( ) sores,
( ) lumps, ( ) sexually transmitted infections and treatments: _____________
VII.REVIEW OF SYSTEM ( ) dyspareunia

GENERAL: ( ) fever, ( ) chills, ( ) weight gain , ( ) weight loss in the past, ( ) fatigue, () weakness URINARY: ( ) polyuria, ( ) dysuria, ( ) hematuria, ( ) flank pain
INTEGUMENT: ( ) dry skin, ( ) unusual change in color, ( ) urinary urgency, ( ) oliguria, ( ) nocturia, ( ) Frequency of urination, ( ) burning or
( ) rashes, ( ) lumps, ( ) sores, ( ) itchiness, ( ) tattoo, ( ) changes in size or color of moles, pain during urination, ( ) urinary infections, ( ) kidney stones,
( ) changes in hair or nails ( ) incontinence, ( ) enuresis, ( ) suprapubic pain
HEENT: In males, reduced caliber or force of the urinary stream, ( ) dribbling,
HEAD: ( ) hair loss, ( ) light headedness, ( ) dizziness, HEMATOLOGIC: ( ) pallor, ( ) easy bruising, ( ) hematoma, ( ) prolonged bleeding, ( ) anemia,
( ) headache, ( ) tenderness, ( ) head injury ( ) past transfusions, ( ) transfusion reactions
EYES: ( ) use of glasses, ( ) contact lenses, ( ) blurring of vision, ( ) eye pain, ( ) redness,
( ) excessive lacrimation, ( ) spots, ( ) flashing lights, ( ) glaucoma, ( ) cataracts.
EARS: ( ) ear ache, ( ) discharge, ( ) tinnitus, ( ) vertigo, MUSCULOSKELETAL: ( ) muscle and joint pain, ( ) muscle weakness, ( ) joint swelling, ( ) stiffness,
( ) impaired hearing, ( ) itching, ( ) infection ( ) muscle wasting, ( ) rigidity, ( ) arthritis, ( ) gout, ( ) back-ache
If hearing is decreased: ( ) use of hearing aids.
NOSE: ( ) epistaxis, ( ) congestion, ( ) discharge, NEUROLOGIC: ( ) memory loss, ( ) nervousness, ( ) seizures, ( ) numbness, ( ) tingling,
( ) itchiness, ( ) Frequent colds, ( ) sinus trouble ( ) speech problem, ( ) sensorial changes, ( ) Changes in mood,
MOUTH AND THROAT: ( ) sores, ( ) swelling, ( ) gum bleeding, ( ) dental caries, ( ) hoarseness, ( ) changes in orientation, ( ) paralysis, ( ) numbness or loss of sensation, ( ) tingling or
( ) sore throat, ( ) dysphagia, ( ) use of dentures, ( ) last dental examination: __________ “pins and needles,” ( ) tremors or other involuntary movements

NECK: ( ) pain, ( ) lumps, ( ) stiffness ENDOCRINE: ( ) cold and heat intolerance, ( ) weight loss, ( ) excessive sweating, ( ) polydypsia,
( ) polyphagia, ( ) change in glove or shoe size.
BREAST: ( ) pain, ( ) lumps, ( ) discharge, ( ) self-breast exam practices
PSYCHIATRIC: ( ) nervousness, ( ) anxiety, ( ) depression, ( ) hallucinations, ( ) memory change,
RESPIRATORY: ( ) chest pain, ( ) dyspnea, ( ) cough, ( ) suicide attempts
( ) sputum production: color: _______, quantity: ________, ( ) wheezing, ( ) hemoptysis,
( ) last chest x-ray: ____________
( ) asthma, ( ) bronchitis, ( ) emphysema, ( ) pneumonia, ( ) tuberculosis

CARDIOVASCULAR: ( ) palpitations, ( ) chest pain,

( ) orthopnea, ( ) paroxysmal nocturnal dyspnea,
( ) edema, ( ) easy fatigability, ( ) varicose veins,
( ) cyanosis, ( ) intermittent claudications,
( ) results of past electrocardiograms: _____________________

GASTROINTESTINAL: ( ) loss of appetite, ( ) vomiting,

( ) nausea, ( ) dysphagia, ( ) abdominal pain,
( ) change in bowel habit, ( ) diarrhea, ( ) constipation
( ) hematemesis, ( ) excessive belching,
( ) hematochezia, ( ) melena, ( ) indigestion, ( ) food intolerance, excessive,
( ) belching or passing of gas, ( ) Jaundice, ( ) liver trouble, ( ) gallbladder trouble,
( ) hepatitis.

PERIPHERAL VASCULAR: ( ) Intermittent claudication, ( ) leg cramps, ( ) varicose veins,

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
 PHYSICAL EXAMINATION □ shuffling □ stumbling □ unable to walk alone
Vital Signs and Anthropometric Measurements □ w/ assistive devices: ___________________
T Oral / axillary / rectal
BP Sitting / lying / standing [R / L] [arm / leg] Skin (use body sketch to note lesions)
PR Regular / irregular Site? General Color □ pallor □ jaundice □ flushing □ cyanosis
HR Regular / irregular Temperature □ cold □ slightly warm □ warm (local / systemic)
RR Regular / irregular Skin Tone □ light □ fair □ dark □ vitiligo
Height Weight Texture □ smooth □ rough □ easily broken □ others:
Waist Hip Turgor □ immediate recoil □ tenting
BMI WHR Moisture □ very dry □ sweaty □ oily □ moist in skin folds
Wrist MUAC Hygiene □ generally clean □ stains _______
Lesions Name
General Survey □ macule (<1 cm) □ petechiae
LOC □ conscious □ drowsy □ patch (>1 cm) □ purpura
□ stuporous □ comatose: Glasgow ___ □ papule (<0.5 cm) □ ecchymosis
Coherence □ coherent □ incoherent □ plaque (>0.5 cm) □ angioma
Orientation □ oriented □ disoriented to: time/person/place □ nodule (0.5 – 1-2 cm) □ telangiectasia
General □ signs of distress □ tumor (>1 to 2 cm) □ varicose veins
Appearance □ cardiorespiratory □ vesicle / blister (<1 cm) □ xanthelasma
□ in pain (use body sketch to locate pain) □ bullae (>1 cm) □ excoriation
□ anxious □ pustule / acne □ maceration
□ cornedo “blackhead” □ ulcer: grade ___
□ nevus “mole” □ fissure
□ wheal □ scar
□ chancre □ keloid
□ fissure □ lichenification
□ stoma □ crusts
□ xerosis (dry, scaly) □ skin cancer
Edema □ non-pitting □ pitting: grading ___
□ pedal edema[R / L] Grade: 1+ 2+ 3+ 4+
Pressure Ulcer Location and Size Stage I II III IV
Vascular Site/s: □ inflammation □ bruising
Insertions □ infiltration □ bleeding
Stoma / Site/s: □ redness □ pallor
Drainage □ purulent □ dry □ wet

Head
Configuration □ normocephalic □ masses _________
□ skull deformation □ depressions _________
Hair □ fine □ coarse □ dry □ breaks easily □ color ______
□ normal distribution □ bald spot □ alopecia
Scalp □ clean □ dandruff □ lice □ lesions

Eyes
Eyelids □ symmetrical □ edema/swelling [R / L] □ ptosis [R / L]
Dev’t □ endomorph □ mesomorph □ ectomorph □ entropion □ ectropion
□ well □ fair □ poor Periorbital □ edema □ sunken □ discoloration
□ looks accdg. To age □ looks younger / older Region □ xanthelasma □ lesions _____________
Nutrition □ well-nourished □ obese □ cachexic Conjunctiva □ pinkish □ pale □ lesion □ discharge □ hemorrhage
Emotional □ calm □ worried □ restless □ tense Sclera □ anicteric □ subicteric □ icteric □ hemorrhage
State □ others: _________________________ Cornea & Lens □ smooth □ clear □ lesions □ opacity □ arcus senilis
Gait □ coordinated □ uncoordinated □ staggering Pupil Size □ equal □ unequal R ___mm L ___mm

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
Reaction to L □ brisk □ sluggish □ fixed
Light R □ brisk □ sluggish □ fixed
Accommodxn □ uniform □ unequal
Convergence □ uniform □ unequal
Visual Acuity □ able to read newsprint with __ font size at __ distance with [R / L / both eyes]
□ grossly normal □ wears glasses / contact lenses
EOM □ coordinated □ uncoordinated
Eyebrows Hair distribution: □ thin □ thick □ lesions
Lacrimal Duct □ easy tearing □ tenderness □ discharge □ inflammation

Nose
Nasolabial Fold □ symmetrical □ shallow [R / L]
Septum □ midline □ deviated □ perforated □ polyps
Mucosa □ pinkish □ pale □ reddish
Discharge □ serous □ purulent □ mucoid □ bloody
Patency □ both patent □ obstructed [R / L] □ masses / lesions __________________
Sense of Smell □ able to smell alcohol through each nostril
□ not able to smell alcohol through [R / L] nostril
Sinuses Frontal □ tender □ nontender □ transilluminated
Maxillary □ tender □ nontender □ transilluminated
Oxygen Support □ cannula □ mask _____________ □ rate: ____________ Neck
Trachea □ midline □ deviation [R /L]
Ears Lymph Nodes □ nonpalpable □ palpable □ enlarged □ tender
External Pinnae □ normoset □ symmetrical □ tenderness □ gross abnormalities __________ Thyroid □ nonpalpable □ enlarged: □ unilateral □ bilateral
□ discrete nodules □ firmly attached □ freely mobile
External Canal □ impacted cerumen □ lesions _____________
Discharge □ foul-smelling □ serous □ purulent □ mucoid Others □ normal ROM □ neck rigidity
□ color __________ □ amount _____________ □ NVE at ____
□ masses: size _______ shape _______
Tympanic □ color __________, □ characteristics __________
Membrane □ cone of light __________
Chest and Lungs
Gross Hearing Whisper test: □ normal □ hearing problem [R L]
Inspection
Mouth and Pharnyx General □ eupnea □ hyperpnea □ tachypnea □ dyspnea
comfort and □ use of accessory muscles _______________
Lips □ pallor □ cyanosis □ dryness / cracks
breathing □ distressed □ diaphoretic □ labored
□ lesions _________ □ mouth sore □ cleft
pattern □ audible wheezing
Tongue □ midline □ deviated [R /L] □ atrophy
Color □ cyanosis __________
□ fasciculations □ lesions □ color
□ clubbing of fingernails
Teeth □ complete □ missing
□ caries □ dentures □ braces/retainers
Inspiration
Gums □ pinkish □ pale □ bleeding □ tenderness
Expiration Ratio
Mucosa Oral: □ pinkish □ pale □ cyanotic
Shape of Chest APL Ratio: ___AP ___L □ barrel □ funnel □ pigeon □ others__________
Pharynx: □ dull red □ pale □ cyanotic □ exudates: color __________
Retractions □ positive □ none
Palate □ lesion _________ □ cleft
Ability to speak □ regular breathing while speaking □ few words _________
Uvula □ midline □ deviated [R / L]
Spine/chest □ positive ________________
Tonsils □ inflammation: grade _____
deformities
Speech □ intact □ slurred □ aphasic □ others ___________________
Chest veins □ prominent □ not seen
Sputum □ color _________ □ amount __________ □ others ____________
Scars □ Remarks: _____________
Palpation
Tender areas □ Remarks: _____________
Chest □ symmetrical □ decrease / lag [R / L]
Expansion

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
Tactile Fremitus □ symmetrical □ inc / dec at [R / L]

For Murmurs, Encircle One:

Trachea □ deviation: ________ □ no deviation

Percussion
Percussion □ resonant [R / L] □ dull [R / L] over __________
□ hyperresonant [R / L] over __________

Auscultation
Breath Sounds □ vesicular over: □ most of lungs □ [R / L] □ I _ E
□ pitch: low / medium / high □ absent
Breast and Axillae
□ bronchovesicular over: □ 1st& 2nd ICS □ I _ E
Size
□ intrascapular □ pitch: low / medium / high
□ bronchial over: □ manubrium □ lobar pneumonia Shape
□ I _ E □ pitch: low / medium / high Symmetry □ equal □ unequal □ engorgement
Adventitious □ rhonchi over ______________ □ wheezes over ______________ Contour □ dimpling _________ [R / L]
Sounds □ crackles / rales □ pleural friction rub □ stridor Skin □ redness □ edema □ lesions _______________
□ vein distention □ warm □ cool
Heart Tenderness □ tender at ___________ □ nontender
Pericordial Area □ flat □ bulging □ normodynamic □ hyperdynamic □ tenderness □ heaves / thrills Nipple and □ inversion □ flattening / retraction □ deviation to [R /L]
PMI at _______________ Areola □ edema □ milk production □ discharges
Jugular Veins □ normal □ distension: lying ___degrees, ___cm Mass □ movable □ Non-movable
Carotid Arteries □ easily palpable □ diminution □ tender □ non-tender
Heart Sounds □ faint □ distinct □ S3 □ S4 S1__S2 at base; S1__S2 at apex □ size: ___________
□ murmur, grade __ best heard at ____________ □ location: _________
□ clicks, best heard at ____________ Borders: □ well-defined □ poorly defined
□ snaps, best heard at ____________ Shape: □ round □ irregular
□ others, best heard at ____________ Consistency: □ soft □ firm □ hard
Percussion □ cardiac dullness from ___ to ___ ICS Axillary nodes □ palpable □ non-palpable

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
 Bladder (post- □ distention
partum) □ tenderness

Back and Extremities

Peripheral □ symmetrical □ regular □ warm □ absent □ faint
Pulses □ weak □ strong □ bounding
Findings (Refer to stick figure below):
Carotid Brach Radial Fem Poplit PT DP
R
L
Nails □ pink □ pale □ cyanosis □ inflammation
□ clubbing □ blanching
Joints □ redness □ warmth □ crepitation
Abdomen □ swelling at _____________
Inspection □ tenderness at _____________
Skin □ dilated veins □ striae □ scar _______________ □ full ROM
□ rashes □ lesions _______________________ □ decreased ROM at _____________
Umbilicus □ sunken □ bulging □ hernia Muscle □ size equal □ atrophy at ______________
Configuration □ flat □ globular □ protuberant □ scaphoid □ normal trone□ hypertonic □ flaccid
□ symmetrical □ asymmetrical □ fasciculation □ tics □ tremors
□ strength equal: score 0 1 2 3 4 5
Peristalsis □ visible □ not visible
□ weakness at _____________
Pulsations □ visible □ not visible
□ paralysis at _____________
Auscultation (Diaphragm)
Fine Motor □ finger-to-nose: □ smooth & accurate □ fail
Bowel Sounds □ normoactive ____/min □ hyperactive ____/min □ hypoactive ____/min
□ heel-to-shin: □ smooth & accurate □ fail
□ absent □ dull □ medium □ loud
□ finger movement: □ smooth & accurate □ fail
Bruit □ absent □ present over _____________
Reflexes □ patellar: grade 0 1 2 3 4
Percussion □ Achilles: grade 0 1 2 3 4
Percussion □ tympanitic □ hyperresonant over ___________
Spine □ midline □ kyphosis □lordosis□ scoliosis
□ dull over ___________ □ fluid wave □ shifting dullness
Palpation
For Peripheral Pulses:
Palpation □ muscle guarding
□ Rebound tenderness □ Blumberg’s sign □ Rovsing’s sign
□ Murphy’s sign

Liver □ tenderness □ non-tenderness

□ liver span ____cm
□ smooth inferior surface □ irregular surface
Spleen □ percussion sign
Kidneys □ kidney punch : __________
□ tenderness
□ enlarged
Aorta □ pulsations
□ size
Psoas Sign □ pain in lifting thigh when resistance is applied on knee
Obturator Sign □ pain when moving bent knee left and right
Fetus LMP ___wks
Fundic Height ____cm
Fetal Position and Lie: [R / L] ______________
Fetal Presentation ____________ □ ballottement
FHR: ______beats/min at _________
Uterus (post- □ ___ fingerbreadth/s below umbilicus
partum) □ firm □ soft

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin
OTHER NOTES:

SIGNIFICANT PE FINDINGS FROM CHART REVIEW:

Revised by: Weng Evangelista and Rusty Chason Joaquin Revised by: Weng Evangelista and Rusty Chason Joaquin