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GENERAL DATA

Informant:_____________________________________ First part to hit the ground (head, back,


Date and time of hands etc.)
interview:_______________________ _______________________
Reliability:_____________________________________ Interventions done (forced movement,
Patients name:________________________________ hilot etc.)
Age: _____ Gender: M F __________________________________________
Date of birth:__________________________________ Encourage the patient to tell story, use open to
Place of birth:______________________________ close ended, dont interrupt, listen carefully,
Civil Status: ____________________________________ summarize periodically, and check out vague
Citizenship: ____________________________________ statements
Religion: ______________________________________ Onset:
Occupation: ___________________________________ _____________________________________________
Residence: ____________________________________ Location:
_____________________________________________ _____________________________________________
Date of Duration:
admission/consultation____________________ _____________________________________________
Time of Character:
admission:______________________________ _____________________________________________
Number of Aggravating factors:
hospitalization:_______________________ _____________________________________________
Date of Last hospitalization and reasons: Alleviating factors:
____________ _____________________________________________
_____________________________________________ Radiation:
Where: _______________________________________ _____________________________________________
CHIEF COMPLAINT: Timing:
__________________________________________________ _____________________________________________
__________________________________________________ Severity (pain scale of 1-10)
HISTORY OF PRESENT ILLNESS ____________________________________________
AMPLE Associated manifestations/ signs and
Allergies: symptoms
_____________________________________________ __________________________________________________
Medications: ________________________________________
_____________________________________________ Medications, dose and frequency:
Past medical illnesses/surgery: __________________________________________________
_____________________________________________ ________________________________________
Last meal: Laboratories done and results:
_____________________________________________ __________________________________________________
Events preceeding the injury: ________________________________________
_____________________________________________ Clinical impression of the doctor and
For trauma patients: (NOI/TOI/POI/DOI) instructions:
Nature Of Incidence: __________________________________________________
_____________________________________________ ________________________________________
Time Of Incidence: PAST MEDICAL HISTORY
_____________________________________________ MEDICAL:
Place Of Incidence: Previous hospitalization, previous diseases
_____________________________________________ (date, reason of hospitalization):
Date Of Incidence: __________________________________________________
_____________________________________________ __________________________________________________
For BURN PATIENTS: ___________________________________
Chemical Electrical Flame Medications:___________________________________
Rule of 9: _____ _____________________________________________
For VEHICULAR ACCIDENT PATIENTS: Immunizations:_________________________________
Where is the patient seated _____________________________________________
__________________________ (driver seat, (For Trauma: Tetanus Toxoid vaccine)
passenger seat, crossing the pedestrian) Childhood diseases:
For FALL patients: _______________________________
Level or number of stairs Childhood immunizations:
____________________ ___________________________
Blood transfusion:
_________________________________ __________________
Allergies (food, drugs): Meal preference meat or veggies:
______________________________ _____________________
SURGICAL: Like salty foods, soy sauce or patis:
Dates:________________________________________ ___________________
Indication:____________________________________ Like sweets:
Type of operation: ______________________________________
_____________________________________________ Any food restrictions:
OB/GYNE _______________________________
MIDAS: Vit.supplements:
Menarche:____________________________________ __________________________________
Interval:______________________________________ Herbal medicines:
Duration:______________________________________ _________________________________
Amount:______________________________________ Glasses of water/day:
S Smoker
Last menstrual period: Brand:________________________________
__________________________ Since when he/she started:
GP (FPAL): __________________________
Gravida, # of When did you quit:
pregnancy:________________________ _________________________________
Para, # of # of sticks or packs per day:
deliveries:___________________________ _________________________
Termed Pack years:
deliveries:______________________________ ______________________________________
Preterm Alcoholic drinker
deliveries:______________________________ What Brand: __________________________
Aborted pregnancy: ___________________________ Since when he/she started:
Living:________________________________________ __________________________
Birth control Methods: When did you quit:
_____________________________ _________________________________
Age of menopause: ________ Bottles per drinking session:
Menopausal symptoms: _________________________
_____________________________ Do you drink? softdrinks
Post menopausal bleeding: How
__________________________ frequent_____________________________________
PSYCHIATRICS:_________________________________ What
_____________________________________________ brand:______________________________________
FAMILY MEDICAL HISTORY Activity of daily living:
Are parents still living, how is their health ___________________________________________
__________________________________________________ Exercises and physical activities:
________________________________________ __________________________________________________
Any family member who passed way due to ___________________
a disease? What disease? Sleep:
__________________________________________________ ___________________________________________
_______________________________________ Sources of stress:
Any family member or relatives with Heart _________________________________
Disease, chole, stroke, kidney disease, Coping mechanism:
arthritis, cancer, diabetes, thyroid problem, ________________________________
mental illness, asthma, PTB/lung disease Work history:
hematologic problems, depression, suicide: __________________________________________________
__________________________________________________ ___________________________________
________________________________________ Type of Family: Nuclear Extended
How many brothers and sisters?
How many people in your house:
___________________
_____________________________________________
Rank in the family:
Place of residence:
_________________________________
__________________________________________________
Hows their health?
______________________________
________________________________
Owned Rented Boarding house
PERSONAL AND SOCIAL HISTORY
Eating habit: (frequency and amount) Apartment 2 Floors 3 Floors
No. of cr. __________ Type of toilet: Manual Itching
Flush Nose bleed
Source of water: Sinus trouble
___________________________________ NECK
drinking water: Swollen glands
____________________________________ Goiter/lumps:
Garbage disposal: __________________________________
_________________________________ Pain: ________________________________________
if collected how frequent:
Stiffness
____________________________
Are there prevalent diseases in the THROAT
community: Soreness
__________________________________________________ MOUTH
________________________________________ Bleeding
Dentures
Sore tongue
REVIEW OF SYSTEMS dry mouth
SYMPTOMS BEFORE ADMISSION, ILLNESS BREASTS
GENERAL Lumps
Weight loss: ______________________________ Pain/discomfort
Weight gain: _______________________________ Nipple discharge
Weakness Self examination
Feels tired CARDIAC
Fever: ______________________________________ BP: ________
SKIN Previous ECG:
Changes in skin color ___________________________________
Changes in hair Rheumatic fever
Changes in nails Murmurs
Changes in moles Chest pain
Sores Dyspnea
Dryness Orthopnea
Rashes Edema
Lumps Palpitations
HEAD RESPIRATORY
Head injury Difficulty of Breathing
Headache Hemoptysis Quantity: __________________
Dizziness Cough
lightheadedness Sputum Color/Quantity: ______________
EYES Wheezing
Vision: ______ Eyeglasses Contact Last Chest X-
lenses ray:_________________________________
Pain: _______ Redness Cataract GIT
Spots/specks Excessive tearing Trouble swallowing
Double/blurred vision Heart burn
Flashing lights Nausea
EARS Vomiting
Difficulty of hearing Hepatitis
Tinnitus Jaundice
Vertigo Constipation
Ear pain Diarrhea:
Infection Appetite:____________________________________
Discharge ___
NOSE Bowel habits:
Frequent colds __________________________________
Congestion Pain:_________________________________________
Discharge _
Stool color: PSYCHIATRIC
____________________________________ Nervousness
Food Tension
intolerance:________________________________ Changes in mood
PERIPHERAL/VASCULAR Depression
Leg cramps Memory change
Claudication Suicidal attempts
Past clots in vein NEUROLOGIC
Swelling In attention or speech
Color change in fingertips during cold Headache
Swelling with redness and pain Dizziness
GENITOURINARY Fainting
Frequency Seizures
Polyuria Blackouts
Nocturia Weakness
Urgency Paralysis
Pain (burning, suprapubic): Tremors
_______________________ Numbness
Hematuria Tingling pins and needles
Hesistancy: HEMATOLOGIC
___________________________________ Easy bruising/ bleeding
Incontinence Anemia
Dribbling Past blood transfusion
GENITALS FOR MALES Reason:_________________________________
Hernias ENDOCRINE
Discharges Thyroid trouble
Sores Heat/cold intolerance
Testicular pain Excessive thirst/hunger
Swelling Excessive sweating
History of STI: Change in shoe size
_________________________________ PHYSICAL EXAMINATION (SIGNS)
Sexual habits/interest/satisfaction: GENERAL SURVEY
_____________________________ ____________________ Apparent state of health:
GENITALS FOR FEMALES ____________________________
Bleeding after intercourse Appropriate body built for age:
Itching _______________________
Vaginal discharges Ambulatory:
(color/characteristics): ______________________________________
______________________________________________ Level of consciousness:
Lumps _____________________________
Sores Skin color/ obvious lesions;
History of STI: __________________________
_________________________________ Dress grooming and personal hygiene;
Sexual habits/interest/satisfaction: Clothing, clean and appropriate for profession
_____________________________________________ and weather, shoes/ slippers, body piercings,
MUSCULOSKELETAL hygiene and grooming appropriate for age,
Muscle or joint pain nail polish
Stiffness ______________________________________________
Gout ______________________________________________
Back ache Facial
Swelling expression:________________________________
Limitation of motion Body
History of trauma/fall odor:______________________________________
Systemic features: Fevers Chills Posture and
Rash gait:_________________________________
Height_________________ Weight: BREAST
_________________ Inspection: shape, color, discharge, lump,
BMI ___________________ swelling, inflammation
Signs of distress: Palpation: nodule, mass
_________________________________ CHEST AND LUNGS
VITAL SIGNS Inspection: deformity, lesions, chest
BP (palpatory first): ________________ retractions
PULSE: _________________________ Palpation: tactile fremitus (tres-tres use base
RESPI RATE : ____________________ of palms), lung expansion
TEMPERATURE: _________________ Percussion: tympanitic, consolidation
SKIN L R to compare both sides
Inspection: lesion, jaundice, nevi, scar Auscultation: (vocal fremitus tres-tres, breath
Palpation: skin turgor, hydration, nodules, sounds, adventitious sounds like wheezes,
cyst, mass rales, egophony)
HEAD L R to compare both sides
Inspection: symmetry, hair distribution, CARDIOVASCULAR
alopecia, scar, visible lesion Inspection: bulging, adynamic precordium,
Palpation: depression, lump, lesion, skull Palpation: PMI, thrills (use palm), JVP (jugular
symmetry pulsation to sternal angle, normal: <3-4cm,
EYES bed at 30 degrees)
Inspection: symmetry, redness, hematoma, Percussion: cardiac size (area of resonance to
excessive tearing, color of the sclera and the dullness, 3rd-6th ICS)
conjunctiva Auscultation: aortic regurgitation (lean
Palpation: tenderness forward then exhale completely and stop
Fundoscopy: red orange reflex, macula, blood breathing in expiration during exhalation)
vessels murmurs, valve sounds, PMI,
check for pupilary reflex, accommodation Aortic (2nd R ICS)
reflex, direct & consensual reflex Pulmonic (2ndL ICS)
check for extraocular muscles integrity Tricuspid (lower L parasternal)
convergence test Mitral (apex PMI- 5th ICS L midclavicular line)
NOSE GASTROINTESTINAL
Inspection: midline, deformity, discharges Inspection: shape, lesion, ascites, jaundice,
Palpation: tenderness of sinuses, epistaxis, umbilical vein dilation, caput medusa
scars, mass Ausculation: bowel sounds, abdominal aorta,
check the turbinates bruits
EARS Percussion: tympanic, mass or air or fluid
Inspection: shape, deformity, lesions, Palpation:, deep and light palpation,
swelling, impacted cerumen tenderness, mass
Palpation: tenderness Rovsings sign, psoas sign, obturator sign,(+)
using the otoscope check for the integrity of ankle jarring- appendicitis,
the tympanic membrane (pearly white/gray) murphys sign- cholecystitis
and look for perforation and inflammation liver span, check for the spleen- if palpation
using tunning fork, assess Rinnes and there is splenomegaly
Webers Test fluid wave test and shifting dullness for
THROAT ascites
Inspection: lesion in the oral, buccal mucosa,
tongue, position of the uvula, tonsilar
inflammation, gag reflex, difficulty in
swallowing
NECK
Inspection: lesions, scars
Palpation: thyroid gland (below cricoids
cartilage, ask patient to swallow), mass,
lymph node
Ausculation: (if hypertensive check for carotid
bruits)

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