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Name of Student: __________________________ Ward: __________ Bed# ____ Date/Time of Interview: ___________________
History/Compatibility/Adjustment: _____________________
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Precipitating/Predisposing factors: ______________________ PAST HEALTH MAINTENANCE HISTORY
__________________________________________________ I. Childhood Diseases
__________________________________________________ ___ Measles ___ Polio
__________________________________________________ ___ Chickenpox ___ Diphtheria/Pertussis/Tetanus
__________________________________________________ ___ Mumps ___ Rheumatic fever
II. Characteristics ___ Rubella ___ Typhoid fever
Character (Quantity, Quality, Consistency, Appearance): ___ Varicella ___ Dengue fever
__________________________________________________ Others: ____________________________________________
__________________________________________________
__________________________________________________ II. Allergies
__________________________________________________ __________________________________________________
Location/Radiation: __________________________________ __________________________________________________
Intensity/Severity (Pain Scale): _________________________
Timing: III. Surgeries
___ Continuous ___ Intermittent Date Indication Type of Operation
___ Rhythmic ___ Remittent
Aggravating/Relieving Factors: _________________________
__________________________________________________
__________________________________________________
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Associated Symptoms: _______________________________
__________________________________________________
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IV. Immunizations
III. Course since Onset ___ BCG ___ OPV
Incidence: ___ DPT ___ Measles
___ Single acute attack ___ Recurrent acute attack ___ Hepatitis B ___ Tetanus toxoid
___ Daily occurrences ___ Periodic occurrences ___ HiB ___ Pneumococcal
___ Continuous chronic episode ___ Varicella ___ Typhoid fever
___ Rotavirus ___ Cholera
IV. Effects of Therapy ___ Rabies ___ Others: __________________
Alleviation due to therapy? Yes ___ No ___
Has drug suppressed or masked symptom/s? Yes ___ No ___ V. Hospitalizations
Toxic effects producing other symptoms: ________________ Date Hospital Diagnosis Procedures
__________________________________________________ Done
Appropriate dosage? Yes ___ No ___
Duration of treatment: _______________________________
Others ____________________________________________
__________________________________________________
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V. Progress
What happened to the symptom/s during the total duration
of illness?
___ Better ___ Worse ___ Unchanged ___ Disappeared VI. Major Illnesses
Notes _____________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
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__________________________________________________ VII. Accidents
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
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VIII. Pregnancies/Deliveries Familial incidences of:
G ___ P ___ Term ___ Premature ___ Living ___ Abortion ___ ___ Diabetes Mellitus ___ Hypertension
___ Cardiovascular Disease ___ Cerebrovascular Disease
# Date of AOG Manner Complications Sex/ ___ Allergies ___ Cancer
Delivery of Condition ___ Mental Illness ___ Others: _____________
Delivery of Baby
ADDENDUM: SEXUAL HISTORY
Age at first coitus: _____ y/o
Date of last sexual intercourse: ________________________
Sexual orientation/preference: ________________________
No. of sexual partners
in the last 6 months __________________________
in the last 5 yrs ______________________________
in the patient’s lifetime _______________________
History of sexually transmitted infections: ________________
__________________________________________________
Others: ____________________________________________ __________________________________________________
__________________________________________________ Routine contraceptive use: Yes ___ No ___
__________________________________________________ Natural Method:
___ Withdrawal
FAMILY HISTORY Rhythm Method:
___ Calendar
Grandparent Age Health Status Cause of Death/ ___ Basal Body Temperature
Age at Death ___ Cervical Mucus
___ Symptothermal
___ Lactation Amenorrhea Method (LAM)
Artificial Method:
___ Chemical barriers (spermicides,
vaginal sponge)
Physical barriers:
___ Diaphragm
___ Cervical cap
Parent Age Health Status Cause of Death/ ___ Condom (male/female)
Age at Death ___ Oral contraceptive pills
___ Injectables
___ Subdermal implants
___ Morning-after pill
___ Contraceptive patch
___ Intrauterine device (IUD)
Permanent Method:
Sibling Sex Age Health Cause of Death/ ___ Vasectomy
Status Age at Death ___ Tubal ligation
ADDITIONAL NOTES
__________________________________________________
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Similar illness/symptom in the family: ___________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
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REVIEW OF SYSTEMS
I. General
___ Fever ___ Sweating ___ Weakness
___ Fatigue ___ Weight Loss
II. Skin
___ Color ___ Texture
___ Itching ___ Rashes
Changes in: ___ Hair ___ Nails
III. Eyes
___ Visual Impairment ___ Double Vision
___ Redness ___ Discharge
___ Tearing ___ Trauma
___ Pain
IV. Ears
___ Hearing Loss ___ Discharge
___ Otalgia ___ Tinnitus
VI. Respiratory
___ Cough/Sputum ___ PTB exposure
___ Difficulty of breathing ___ Hemoptysis
___ Wheezing (asthma)
VII. Cardiovascular
___ Palpitation ___ Hypertension
___ Syncope ___ Orthopnea
___ Chest pain ___ Dyspnea
___ Edema
VIII. Gastrointestinal
___ Dysphagia ___ Heartburn
___ Nausea ___ Hematemesis
___ Vomiting ___ Fatty food intolerance
___ Appetite ___ Stool frequency/
___ Abdominal pain character
___ Melena ___ Hemorrhoids
___ Jaundice ___ Abdominal distention
___ Bleeding ___ Hernia
___ Indigestion
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IX. Urinary DESCRIPTION
___ Pain ___ Stones
___ Volume ___ Infection
___ Retention ___ Hesitancy
___ Bleeding ___ Urgency
___ Stream ___ Change in color
___ Polyuria ___ Frequency
___ Nocturia ___ Dribbling
X. Genitoreproductive
Male: ___ Discharge ___ Libido
___ Pain ___ Sexual difficulties
Female: Menarche _______ y/o
LMP ______________
PMP ______________
Menses: ___ Regular Duration: ________________
Amount: ____________________________
___ Abnormal vaginal bleeding
___ Dysmenorrhea/pelvic pain
___ Post-coital bleeding
___ Discharge ___ PID
___ Contraceptive use # of Pregnancies: _____
Complications: _________________________________
Live Births: _____ Heaviest baby: _____ lbs
Menopause age: _____
___ Post-menopausal bleeding
XI. Breast
___ Nipples ___ Pain
___ Lump ___ Discharge
XII. Extremities
___ Cyanosis ___ Varicosity
___ Clubbing ___ Ulcers
___ Edema ___ Claudication
XVII. Psychiatric
___ Mood swings ___ Anxiety
___ Behavioral changes ___ Depression
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PHYSICAL EXAMINATION
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III. Skin & Hair DESCRIPTION
Color: ___ Redness/flushing ___ Pallor
___ Increased pigmentation ___ Cyanosis
___ Decreased pigmentation ___ Jaundice
Texture: ___ Rough/Dry ___ Smooth
Moisture: ___ Dry ___ Wet/clammy ___ Oily
Turgor: ___ Good ___ Fair ___ Poor
Temperature: ___ Symmetrical ___ Non-symmetrical
___ Rashes (describe)
___ Lesions: ___ Primary ___ Secondary Type: ________________________________________________
Color: _______________________________________________
Size: _________________________________________________
Pattern: ___ Linear ___ Annular/Ring-like
___ Iris/target ___ Grouped
___ Herpetiform ___ Zosteriform
Nails: ___ Oil spots ___ Loosening ___ Lesions Shape: _______________________________________________
___ Crumbling ___ Pitting Distribution: ___ Localized ___ Generalized
Hair: ___ Coarse ___ Dry ___ Smooth and soft Location: _____________________________________________
___ Alopecia: ___ Diffuse ___ Patchy ___ Total Effect of Pressure: ___ Blanching ___ Non-blanching
V. Cardiovascular
Periorbital region: ___ Edema/Swelling ___ Sunken
Conjunctiva: ___ Pinkish ___ Pale
Lips: ___ Pallor ___ Cyanosis
___ Dry/Cracked ___ Lesions
Tongue size: ___ Enlarged
Gums: ___ Pinkish ___ Pallor
___ Bleeding ___ Tenderness
Buccal mucosa: ___ Pinkish ___ Pale
Pharynx: ___ Pinkish ___ Reddish ___ Pale
Jugular venous pulse: ____ cm w/ head of bed elevated at ____ °
Carotid Artery: ___ Thrills ___ Bruits
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DESCRIPTION
Precordium: ___ Flat ___ Adynamic
___ Bulging ___ Dynamic
___ Tenderness ___ Heaves
___ Thrills
PMI at: ______________________________________________
Heart Sounds: ___ Distinct ___ Faint
S1 _____ S2 at the base
S1 _____ S2 at the apex
Extra heart sounds: ___ S3 ___ S4
___ Murmurs (Grade: _____)
Nails: ___ Cyanosis ___ Pallor
___ Clubbing ___ Spooning
Capillary refill time: _____ secs
___ Edema of the extremities: ___ Bilateral
___ Unilateral
___ Pitting
___ Non-pitting
Peripheral pulses: ___ Symmetrical ___ Regular
___ Asymmetrical ___ Irregular
___ Weak ___ Strong
___ Faint ___ Bounding
___ Absent Grade: _________
VI. Gastrointestinal/Abdominal
Skin: ___Scars ___ Striae
___ Dilated veins ___ Rashes & lesions
Umbilicus: ___ Sunken ___ Bulging
___ Inflammation
Contour: ___ Flat ___ Bulging of flanks
___ Rounded ___ Symmetrical
___ Protuberant ___ Asymmetrical
___ Scaphoid ___ Visible organs/masses Characteristics of mass
Location: _____________________________________________
___ Visible peristalsis ___ Increased pulsations Size: _________________________________________________
Bowel sounds: _____ /min ___ Borborygmi Shape: _______________________________________________
___ Increased ___ Abdominal bruits Consistency: __________________________________________
___ Decreased ___ Friction rub Tenderness: __________________________________________
___ Absent ___ Venous hum Pulsations: ___________________________________________
Note on Percussion: ___ Hypertympanic ___ Tympanic Mobility with respiration or with the examining hand: _________
___ Dullness at _____________________ _____________________________________________________
___ Shifting dullness
LIVER:
Liver size: ________________ cm/in
Tenderness on percussion: ___ Yes ___ No
Tenderness on palpation: ___ Yes ___ No
___ Soft, sharp, regular edge with smooth surface
___ Firm/hard, blunt/rounding of edge, irregular contour
SPLEEN:
Dullness on percussion: ___ Yes ___ No
___ Splenic percussion sign
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___ Non-palpable ___ Palpable DESCRIPTION
___ Non-tender ___ Tender
AORTA:
Aortic pulsations: ___ Yes ___ No
VII. Genitourinary
KIDNEYS:
___ Non-palpable ___ Palpable
___ CVA tenderness
BLADDER:
___ Non-palpable ___ Palpable
___ Non-tender ___ Tender
Dullness on percussion: ___ Yes ___ No
Male
Skin: ___ Redness ___ Discoloration
___ Papules ___ Pustules
___ Macules ___ Vesicles
___ Ulcers ___ Nodules
___ Plaques ___ Excoriations
___ Others: ______________________________________
Pubic Hair: Distribution: _________________________________
___ Nits ___ Lice
Prepuce: ___ Phimosis ___ Paraphimosis ___ Smegma
Penis: ___ Discharge ___ Tenderness
___ Ulcers ___ Scars
___ Swelling ___ Nodules
___ Induration
Urethral Meatus: ___ Hypospadia ___ Epispadia
Scrotum: ___ Equal ___ Unequal
___ Edema at R/L ___ Enlargement at R/L
___ Tenderness ___ Undescended at R/L
___ Rashes ___ Nodules
___ Veins ___ Lumps
___ Epidermoid Cysts ___ Bulging
Prostate: ___ Smooth ___ Firm
___ Rubbery ___ Non-tender
___ Swelling ___ Tender
___ Bogginess ___ Warm
___ Nodules
Bulging: ___ External Inguinal Ring ___ Internal Inguinal Ring
___ Anterior thigh (femoral canal)
Female
Mons Pubis: ___ Excoriations ___ Itchiness
___ Redness ___ Papules
___ Macules ___ Pustules
___ Plaques ___ Vesicles
___ Ulcers ___ Nodules
___ Others: ________________________________
Pubic Hair: Distribution: _________________________________
___ Nits ___ Lice
Clitoris: ___ Enlargement
Urethral Meatus: ___ Caruncle ___ Prolapse
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Labia: ___ Symmetrical ___ Asymmetrical DESCRIPTION
___ Tenderness ___ Discoloration
___ Redness ___ Edema/Swelling
Hymen: ___ Intact ___ Imperforated
Vaginal Introitus: ___ Inflammation ___ Swelling
___ Vesicles ___ Pustules
___ Ulcerations ___ Nodules
___ Others: ____________________________
___ Discharge: ___Serous ___ Purulent
___ Mucoid ___ Foul-smelling
___ Whitish, curd-like ___ Others
I. Mental Status
Instructions: Ask the questions in the order listed. Score one point for each correct response within each question or activity.
30 TOTAL
*Adapted from Rovner & Folstein, 1987
DESCRIPTION
II. Cranial Nerves
CN I (Olfactory): ___ Intact
___ Anosmia (unilateral/bilateral)
CN II (Optic):
Visual acuity:
VA (w/correction) OD ________
OS ________
(w/out correction) OD ________
OS ________
___ Counting fingers at _____ ft
___ Hand movement at ___ RUQ ___ LUQ
___ RLQ ___ LLQ
___ R temporal ___ L temporal
___ R nasal ___ L nasal
___ Light projection at _________________ quadrant/s
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DESCRIPTION
___ Light perception: ___ Vague ___ Erratic Confrontation Field Diagram:
Visual fields: (see column 2: Confrontation field diagram)
Fundoscopy: T N T
Media: ___ Clear ___ Hazy
Disc borders: ___ Distinct ___ Blurred
*Cup disc ratio = _____ : _____
**Arteriole-venule ratio (AVR) = _____ : _____ LE RE
AV Crossing: ___ Normal ___ AV Nicking
___ Banking ___ Tapering and banking
Red orange reflex: ___ Positive ___ Negative
___ Hemorrhages ___ Exudates *Normal Cup-disc ratio = 0.4 – 0.5
___ Papilledema ___ Glaucomatous cupping **Normal Arteriole-venule ratio (AVR) = 2:3
___ Optic atrophy ___ Microaneurysms
___ Neovascularization ___ Hypertensive retinopathy
___ Macular Star ___ Diabetic retinopathy
___ Drusen ___ Healed chorioretinitis
Reflexes: ___ Optic blink reflex ___ Red orange reflex
CN III, IV, VI (Oculomotor, Trochlear, Abducens):
Primary gaze: ___ In midline ___ Disconjugate
Eye Movements: ___ Esotropia ___ Strabismus
___ Exotropia ___ Diplopia
Convergence: ___ Equal ___ Unequal
Pupil size: ___ Equal ___ Unequal
R = _____ mm L = _____ mm
Pupillary response to light: *Pain, temperature, light touch
___ Reactive ___ Parallel
___ Brisk ___ Sluggish
___ Fixed ___ Swinging light reflex
Accommodation: ___ Responsive ___ Non-responsive
CN V (Trigeminal):
Reflexes: ___ Jaw jerk reflex ___ Corneal reflex
*Facial sensation: ___ Intact ___ Impaired
Motor function: ___ Intact ___ Paralysis at R/L
___ Weakness at R/L
CN VII (Facial):
Motor function: ___ Intact ___ Weakness at R/L
___ Symmetrical ___ Paralysis at R/L
___ Asymmetrical
Taste sensation (anterior 2/3): ___ Intact ___ Impaired
CN VIII (Vestibulocochlear):
Rubbed hair/fingers heard at ____ cm (AD) & ____ cm (AS)
Weber’s Test: ___ In midline ___ Lateralizes to R/L ear
Rinne’s Test: ___ : ___ (air conduction to bone conduction)
CN IX & X (Glossopharyngeal & Vagus):
Gag reflex: ___ Intact ___ Absent
Uvula: ___ In midline ___ Deviated to R/L
Palate: ___ Intact ___ Weakness on the R/L
Taste sensation (posterior 1/3): ___ Intact ___ Impaired
Speech: ___ Hoarseness ___ Nasal twang
Swallowing: ___ Coordinated ___ Impaired
CN XI (Spinal Accessory):
SCM: ___ Intact ___ Weakness at R/L ___ Paralysis at R/L
Trapezius: ___ Intact ___ Paralysis at R/L
___ Weakness at R/L
CN XII (Hypoglossal):
Tongue: ___ In midline ___ Deviation to R/L
___ Atrophy ___ Fasciculations
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III. Motor Function DESCRIPTION
Involuntary movements: ___ Tics ___ Choreoathetosis
___ Tremors ___ Fasciculations NUMERICAL SCALE TO RECORD MUSCLE STRENGTH
Strength: _____/5 located at (see column 2 – Muscle Groups) (British Medical Research Council)
___ Tenderness ___ Pronator drift ___ Gowers’ Sign Score Description
Tone: ___ Normal ___ Flaccid ___ Spastic ___ Rigidity 5 Normal strength
Bulk: ___ Atrophy ___ Hypertrophy ___ Pseudohypertrophy 4 Moves joint through full range against resistance
greater than gravity but examiner can overcome
the action (make a percentage estimate of
strength to compensate for broad range of this
number)
3 Moves part full range against gravity but not
against any resistance
2 Moves part only when positioned to eliminate
gravity
1 Only flicker of contraction of muscle but cannot
move joint
0 Complete paralysis
*Compare proximal/distal, right/left, upper/lower
from De Myer’s Neurologic Examination 6th Ed, pg. 248
VI. Reflexes
Superficial/Primitive Reflexes
___ Snout ___ Rooting
___ Sucking ___ Palmar grasp
___ Plantar grasp ___ Babinski
___ Abdominal ___ Cremasteric
Deep Tendon Reflexes (grade using diagram on column 2): Reflexes (grade):
Biceps Triceps
Brachioradialis Knee
Ankle jerk
___ Hoffman’s ___ Clonus
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