Medicine

General Data
Name: ___________________________________________________Age_____Sex_____Civil status_____ Religion______________
Address:_____________________________________________ Birthdate________________________ Race____________________
Birthplace:____________________________ _______________Occupation________________________________%Reliability_______
Date of consultation____________________________ #of Admission_______ Referring physician:_____________________________

Chief complaint:
______________________________________________________________________________________________

History of the Present Illness:

Onset:____________________________________________________ Location ___________________________________________
Precipitating factor _________________________________________ Relieving factor______________________________________
Quality ___________________________________________________ Radiation ___________________________________________
Severity __________________________________________________ Timing _____________________________________________
Associated manifestation_________________________________________________________________________________________
Medications ___________________________________________________________________________________________________
Consultation___________________________________________________________________________________________________
LMP:____________________________________________________ EDC: ______________________________________________
PMP ____________________________________________________
AOG:_________________________________________________

OB- GYNE History

a. OB score __________________________________
GRAVIDA DATE OF INSTITUTION MANNER OF SEX Complications TERM WEIGHT
DELIVERY DELIVERY

b. Prenatal History
a. AOG first cognizant __________________ by ( ) amenorrhea, ( ) pregnancy test
b. Probable sx of preg ______________________________________________________________________________
__________________________________________________________________________________________________
c. 1st prenatal checkup __________________________ ( ) Ultrasound: ___________________________________
d. Subsequent checkup (frequency) ____________________________________________________________________
e. Lab exam & FIndings: ____________________________________________________________________________
f. Illness during preg_______________________________________________________________________________
g. Operations
_______________________________________________________________________________________________
h. ( ) Drugs, ( ) alcohol, ( ) cigarette , ( ) radiation, ( ) others ________________________________
 c. Sexual History:
a. First coitus ____________ # of partner: ___________________ Satisfaction ___________________
b. Frequency _________________________ Dyspareunia ___________________________
d. Gynecologic History:
a. Gynecologic Illness
b. Gynecologic Operation
c. Hormonal tx______________________________ ( ) Fertility workup
d. Papsmear _______________________________________ Family planning _________________________________

Past Personal and Medical History

Birth ________________________________________________ Immunization _______________________________________
Growth ______________________________________________ Childhood diseases ___________________________________
Allergies_______________________________________________________________________________________________________
Regular drug intake: ( )Laxative ( ) Tea/coffee, ( )Alcohol, ( ) Tobacco, ( ) Sleeping pills, ( ) Supplements
o Smoking
o Alcohol
Hospital admissions/ check-ups ____________________________________________________________________________________
o Exact date
o Duration
o Medications
o Procedures
o Hospital
Operations____________________________________________________________________________________________________
Accidents _____________________________________________________________________________________________________

Social and Environmental History

Social:
Educational attainment ________________________________________ Occupational history_______________________________
Living arrangement
Physical aspects of the home
Number of storey_______________ Number of rooms________________ Occupants_____________
Finances_____________________________________________________ Sexual outlet ____________________________________
Habits
o Sleeping o Drinking water
o Eating o Studying habit
Lifestyle
o Diet
o Activity
Environmental history:
Toilet ___________________________ Garbage disposal _________________________________
drinking water________________________Sanitation________________________________________ Pets_____________________
Family History
Parents
Siblings
Position in the family
Marital status
Health status of spouse
Children/ offspring
Heredofamilial diseases

ROS:
1. General: ( ) fatigue, ( ) weight change, ( ) fever, chills, ( ) night sweats, ( ) dizziness
2. Skin: ( ) rash, ( ) itching, ( ) mole, ( ) sore, ( ) hives, ( ) pigmentation
3. Head and Neck: ( ) headache, ( ) trauma, ( ) pain, ( ) stiffness, ( ) swelling
a. Eyes: ( ) pain, ( ) diplopia, ( ) scotoma, ( ) visual dysfunction, ( ) dryness, ( ) redness, ( ) tearing,
( ) use of corrective lens
b. Ears: ( ) deafness, ( ) tinnitus, ( ) pain, ( ) discharges, ( ) vertigo/ dizziness
c. Nose: ( ) epistaxis, ( ) dryness, ( ) pain, ( ) discharge, ( ) obstruction, ( ) smell dysfunction,
( ) sneezing
d. Mouth: ( ) soreness, ( ) pain, ( ) ulcers, ( ) hoarseness, ( ) dryness, ( ) gum & ( ) dental problem
4. Breasts: ( ) discharge, ( ) lump, ( ) pain, ( ) bleeding, ( ) infection
5. Respiratory: ( ) cough, ( ) dyspnea, ( ) sputum, ( ) hemoptysis, ( ) cyanosis, ( ) asthma, ( ) occupational
exposure, ( ) TB, ( ) previous chest x-ray
6. cardiac: ( ) chest pain, ( ) orthopnea, ( ) palpitation, ( ) fatigue, ( ) edema, ( ) cyanosis, ( ) syncope,
( ) hypertension, ( ) past heart disease, ( ) exercise limit
7. Vascular: ( ) intermittent claudication, ( ) leg cramp, ( ) varicose vein
8. Gastrointestinal: ( ) anorexia, ( ) nausea, ( ) vomiting, ( ) dysphagia, ( ) hematemesis, ( ) indigestion,
( ) melena, ( ) hematochezia, ( ) heartburn, ( ) abdominal pain, ( ) abdominal distention,
( ) jaundice, ( ) diarrhea, ( ) constipation, ( ) change in bowel habit, ( ) hernia, ( ) hemorrhoids, ( ) use of
laxative
9. Renal and urinary: ( )dysuria, ( )hematuria, ( )incontinence, ( ) nocturia, ( ) urinary frequency, ( ) dribbling,
( ) kidney stones
10. Male Genitalia: ( ) pain, ( ) swelling, ( ) urethral discharge, ( ) hernia, ( ) testicular pain, ( ) masses,
( ) history of venereal diseases, ( ) erectile dysfunction, ( ) ulcers
11. Musculoskeletal: ( ) muscle pain, ( ) joint pain, ( ) cramps, ( ) weakness, ( ) stiffness, ( ) history of trauma,
( ) swelling, ( ) limitation of motion, ( ) backache
12. hematological: ( ) anemia, ( ) excessive bleeding, ( ) easy bruising, ( ) past transfusion
13. Endocrine and metabolic: ( ) heat/cold intolerance, ( ) weight change, ( ) thyroid problem, ( ) excessive sweating, (
) polydipsia, ( ) polyphagia, ( ) weakness, ( ) head trauma
14. Nervous system: ( ) headache, ( ) syncope, ( ) seizure, ( ) weakness, ( ) head trauma, ( ) stroke, ( ) sleep
disorder, ( ) coordination problem, ( ) sensory disturbance, ( ) motor problem, ( ) tremor, ( ) memory
15. Psychiatric/ Emotional: ( ) anxiety, ( ) depression, ( ) loss of control, ( ) nervousness, ( ) memory change,
( ) suicide attempts, ( ) substance abuse
Physical Examination
BP: RR: PR: TEMP:
Ht: Wt: BMI: IBW:

General survey:

Integument:

HEENT:

Respiratory:

Cardiac:

Breast:

Abdomen:
Fundic Ht____________________ Estimated fetal wt ___________________________- Fetal heart tone & loc._________________
Leopolds:
LM1__________________________________________________________________________________________________________
LM2__________________________________________________________________________________________________________
LM3 __________________________________________________________________________________________________________
LM4 __________________________________________________________________________________________________________

Extremities:

Pelvic exam: