HISTORY AND PHYSICAL EXAMINATION

Surgical Procedures:
Date of Interview: _______________________________________ Date: _____________________________________________
Time of History: _________________________________________ Type of Operation: __________________________________
Informant: ______________________________________________ Purpose: __________________________________________
Relationship to the Patient: _______________________________ Previous Hospitalizations:
% Reliability: ____________________________________________ Date Cause Hospital Treatment

GENERAL DATA
Patient’s Name: __________
Age: __ ___ Sex: ___ __ Marital Status: __________________
Address: _________________
Birthday: ________ Birthplace: ____________ Screening Tests:
Nationality: ______ Religion: _____________ Test Date Result
Occupation: ______ Tuberculin Test
Date of Admission: ________ Pap Smear
Time of Admission: ________ Mammogram
No. of times admitted at QCGH: _ Occult blood in stool
Cholesterol test
CHIEF COMPLAINT Urinalysis
X-ray/CT Scan/MRI
________________________________ Coagulation Test

HISTORY OF PRESENT ILLNESS

Onset: _________ ________________________ MENSTRUAL AND OBSTETRIC HISTORY
Duration: ________ LMP: ________________ PMP: ________________
Frequency: _______ Age of menarche: ____________ Period: Regular/Irregular
Location: ________________ Character of flow: ___________________________________
Precipitating Factors: ________________________________ Duration of period (range): ____________________________
Quality: _________________ No. of pads used per day: _____________________________
Radiation: ________________________ PMS: _____________________________________________
Severity: __ Age of Menopause: _________
Aggravating Factors: ______ Age of 1st coitus: _____ No. of sexual partners: _____
Alleviating Factors:_______________________________________ History of post-coital bleeding, pelvic infection, dyspareunia:
Previous Treatment for the Problem: _______________________ __________________________________________________
Associated Signs and Symptoms: Birth control methods used:
________________________________________ Artificial Natural
________________________  condom  rhythm method
Additional Notes:  pills  withdrawal
________________
 spermicidal  abstinence
_________
Others: ____________________________________
________ _________
Length of time used: __________________________
Complications: ______________________________
PAST MEDICAL HISTORY
Gravidity: _____ Parity: _____
Current Medications:
OB Index: _____________ Term
Generic Brand Dosage Frequency Purpose _____________ Preterm
_____________ Abortions/Miscarriages
_____________ Living Children

Date of Birth Sex Manner of Delivery

Immunizations:
 BCG  DPT  Polio  Hepa B  Measles
Others: ____________________________________________
Allergies: OB History: G ___ P ___ (T-P-A-L)
Food: ______________________________________ G1: When: __________, NSD or CS d/t: _________, delivered by
Medications: ________________________________ _________, where __________, M/F, weight __________, feto-
Pollen/Animals/Others: ______________________ maternal complications __________, present status __________.
Childhood Illness:
 Rheumatic Fever  Polio FAMILY HISTORY
 Chicken Pox  Measles Family Age Health/Diseases Age and Cause of
 Mumps Member Date of Death
Others: ____________________________________ Dx
Adult Illness: Father
Illness Age Date of Diagnosis Mother
HPN Others
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Others
Medical Problems for any blood-relative Head
Disease Relationship to Px Age and Date of  Headache
Dx Dizziness  Tenderness
Cancer  Lightheadedness  Trauma
HPN  Syncope
Diabetes Eyes
TB  Pain  Redness
Heart Disease  Double vision  Blurred vision
Stroke  Use of glass/lenses  Photalgia
Kidney  Lacrimation
Arthritis Ears
Blood Disorder  Hearing problem  Earache
Asthma  Discharge (color/consistency): ____________
Epilepsy  Itching
Mental Disorder Mouth and Throat
Galbladder dse  Use of dentures  Mouth sores
 Bleeding gums  Sore throat
PERSONAL AND SOCIAL HISTORY  Hoarseness  Dysphagia
No. of years married: ______  Toothache
No. of Children: _____ __________ Neck
Health Status of Children: _________________ ________  Pain  Stiffness
Highest Educational Attainment: __________________________  Lump
Occupational History: Breast
________________________________________  Pain  Discharge
Occupational Hazards: ___________________________________  Lumps .Periodic exam
Respiratory
Smoking Habits Cough  Sputum color/quantity): ____
 non-smoker  smoker  ex-smoker Hemoptysis  Dyspnea
No. of sticks/packs per day: ______________________________ Wheezing
Year started: __________ Year quitted: ___________ Cardiovascular
 Chest pain  Palpitations
Alcohol Consumption  Orthopnea  Edema
 never  ocassionally  daily  weekly  Cyanosis  Paroxysnal Nocturnal Dyspnea
Alcohol type: ______  Easy Fatigability
Amount consumed: ________________________ Gastrointestinal
Nutrition
 Loss of appetite  Nausea
No. of meals per day:______________
 Vomiting  Hematemesis
Food preferences:
 Abdominal pain  Dysphagia
Coffee/Tea/Soda intake: ______________________
 Hematochezia  Diarrhea
Nutrient Supplement: ____________________________
 Hemorrhoids  Constipation
OTC: _______________________________________________
Prohibited Drugs: __________________________________  Stool: ________________
Substance Abuse: ___________________________________ Renal
Exercise:__________________  Dysuria  Polyuria
Regularity of Sleep:________________________  Nocturia  Gross Hematuria
Habits/hobbies: ____________________________________  Incontinence  Urinary Retention
Sources of stress: __ ________________________  Urinary Urgency  Tea-Colored Urine
Coping Strategies: ________ __ __________________________ In Males:
 Reduced caliber of force of stream
Living Conditions:  Hesitancy
No. of years in current residence: __________________  Dribbling
Previous place of residence: _______________________ Genitalia
Type of residence: ________ ________________  Pain  Swelling
No. of rooms: ___________________________________  Discharge (characteristics): ___________________
No. of occupants: _______________________________  Ulcers  Itching
Relationship to occupants: ________________ ______ Peripheral Vascular
Source of Drinking Water: ________________________  Leg cramps  Varicose veins
Garbage Disposal: _____________ __________________ Musculoskeletal
Fecal Disposal: ____  Muscle weakness  Stiffness
Pet/s: __________________________________________  Backache  Joint swelling
Personally gives bath to pets: Y/ N  Muscle pain  Joint pain
General state of neighborhood: Neurologic
 Paralysis  Numbness
 Tremors  Seizures
REVIEW OF SYSTEMS  Memory Loss
Constitutional Hematologic
 Fever  Easy bruising  Bleeding
 Weight gain/loss  Pallor
 Chills  Fatigue Endocrine
Skin  Polydipsia  Polyphagia
 Rashes  Itching  Heat/cold intolerance Excessive sweating
 Lumps  Dryness Psychiatric
 Color change  Changes in nails  Nervousness  Depression
Hair  Anxiety Hallucinations
 Baldness  Excess hair
PHYSICAL EXAMINATION
General Survey
Mood: ____________________________________________
Distress/Unusual Position: ____________________________
Cooperative / Non-cooperative: ________________________
Irritated / Agitated / Pleasant: _________________________
Coherent: _________________________________________
Oriented to time and space: ___________________________
Personal Hygiene: ___________________________________
Level of Consciousness: _______________________________
Height: ____________________________________________
Weight: ___________________________________________
BMI: ______________________________________________
Vital Signs
Temperature: _______  Oral  Axillary Rectal
Respiration: ________  Normal  Labored
Pulse: _____________  Regular  R. Irregular
 Irr. irregular
Blood Pressure: _____ Lying  Sitting  Standing
Head
Trauma: ___________________________________________
Size: __________ Shape: ______________________
Tenderness: ________________________________________
Condition of hair and scalp: ___________________________
Symmetry: _________________________________________
Masses: ___________________________________________
Eyes
Visual Acuity:
Far: (R) _________ (L) _________
Near: (R) _________ (L) _________
Visual Fields (H-test): ________________________________
Accommodation: ____________________________________
Test of confrontation: ________________________________
Conjunctiva:
Color: ______________________________________
Discharge: __________________________________
Sclerae
Color: ______________________________________
Discharge: __________________________________
Cornea
Clarity: _____________________________________
Corneal Arcus: _______________________________
Lids: ______________________________________________
Position of eyes in orbits: _____________________________
Pupil
Size: (R) ____________ (L) _____________
Shape: _____________ Symmetry: ____________
Accommodation: ____________________________
Light reflex test (PERLA): ______________________
EOM: ______________________________________
Visual Field: _________________________________
Direct Reaction: ________ Consensual Reaction: _________
Fundoscopy
Red orange reflex: ___________________________
Disc: _______________________________________
Macula: ____________________________________
Blood vessels: _______________________________
Ears
Symmetry: _________________________________________
 Swelling: _________________________________________
 Redness: _________________________________________
 Discharge: _______________________________________
 Tenderness: ______________________________________
 Hearing Impairments: ______________________________
 Presence of Hearing Aid: ____________________________
Weber Test: ________________________________________
Rinne Test: (R) AC _______ (BC) _______
(L) AC _______ (BC) _______
Nose
Symmetry: _________________________________________
Frontal, Maxillary sinus tenderness: _____________________
Obstruction: _______________________________________
Congestion: ________________________________________
Lesions: ___________________________________________
Exudates: __________________________________________
Inflammation: ______________________________________
Throat
Lips: ______________________________________________
Teeth/dentures: ____________________________________
Gums: ____________________________________________
Tongue: ___________________________________________
Pharynx: ___________________________________________
 Lesions: __________  Erythema: ________
 Exudates: _________ Tonsillar size: _______
Neck
Symmetry: _________________________________________
Limitation of ROM: __________________________________
Tenderness: ________________________________________
JVP: ______________________________________________
Lymph nodes: ______________________________________
Size: _______________________________________
Mobility: ___________________________________
Tenderness: ________________________________
Borders: ___________________________________
Consistency: ________________________________
Thyroid Cartilage: _______ Cricoid cartilage: _______
Thyroid gland: ______________________________________
Chest and Lungs
Inspection
Comfort and Breathing Pattern: _______________________
Shape of the Chest: __________________________________
Chest Movement: ____________________________________
 Use of Accessory Muscles of Breathing:
 Deformities or Asymmetry
 A/N Retraction of Interspaces on Inspiration
 Retraction of the interspaces when breathing
Color of Patient (Lips and Nail Bed): ______________________
Palpation
 Tender Areas: ________________________________________
th
Respiratory Expansion (10 rib): __________________________
 Tactile Fremitus:
Increased  Decreased  Absent 
Percussion: _________________________________________
Auscultation: ________________________________________
Breath Sounds:________________________________________
 Bronchophony  Whispered Petoriloquy
 Egophony
Heart
Inspection
Precordial bulge or heave: ____________________________
PMI: ______________________________________________
Palpation
PMI: ______________________________________________
Thrill: _____________________________________________
Location: ___________________________________
Timing in Cardiac Cycle (S/D): _________________
Mode of Extension / Transmission: ______________
 Friction Rub: ______________________________________
Percussion: Cardiac Borders NEUROLOGICAL EXAMINATION
Right (cm) ICS/MSL Left (cm) Mental Status Examination
th
5 A. Awareness
th
4 Orientation
3
rd
Name:  Season  Date  Day  Month  Year
2
nd
Name:  Hospital  Floor  Town  State  Country
Level of Consciousness:
Auscultation B. Speech (Normal, dysphasia, dysarthria, dysphonia)
S1 (M-loud, T-split): __________________________________ C. Language
S2 (A,P-loud, P-split I): ________________________________ Name:  Pencil  Watch
S3: _______________________________________________ Repeat: “ No ifs  ands  or buts”
Murmurs/ Accessory Heart Sounds: D. General Knowledge
Location:_______________ Timing:______________ Knowledge of current events, vocabulary
Quality:________________ Pitch:_______________ (Historical events, 5 last presidents, 5 largest cities)
Intensity:_______________ Radiation:___________ E. Memory
Immediate, recent, remote
Breast F. Registration (Retention and Recall)
Symmetry:_________________________________________ Identify:  Object 1  Object 2  Object 3
 Dimpling/Skin Retraction:____________________________ Attention and Calculation
 Swelling:_________________________________________ (100-7…):  93  86  79  72  65
 Discoloration (Skin changes):_________________________ Recall
 Orange Peel Effect:_________________________________ Recall:  Object 1  Object 2  Object 3
Position and Characteristics of Nipple:___________________ G. Reasoning
 Gynecomastia (Male):_______________________________ Judgment, Insight, Abstraction (interpretation of
 Mass: proverbs)
Location:___________________________________ H. Object Recognition
Size: _____________ Consistency:_______________ Agnosia (Visual, tactile, auditory autotopagnosia,
Tenderness:___________ Mobility:______________ anosognosia)
Borders:____________________________________ Praxis (Ideomotor, Ideational)
Perception (Delusion, Hallucination, Illusion,
Abdomen Astereognosis, Agraphestesia)
Inspection I. Follows Command
 Irregular Contours:___________________________  Scars  Take this paper.  Fold it in half.
 Discoloration: _____________________________________  Place it on the table
 Bulges: __________________________________________  Obey written Command.
Shape: ____________________________________________  Write a sentence
 Striae:___________________________________________  Copy a design.
Distance of umbilicus from xiphoid process: ______________ Total: _____________________________________________
Abdominal Girth:____________________________________
Auscultation Cranial Nerve Examination
Bowel Sounds: Frequency:__________ Character:__________ CN I
 Bruit:____________________________________________  Identify odorant
 Venous Hum:_____________________________________ CN II
 Friction Rub:______________________________________ Visual acuity:_____________ Visual Field: ________________
Percussion Fundoscopy: _______________________________________
Liver Span:__________________ Normal: 6-12 cm in (R) MCL CN III, IV, VI
Splenic Dullness:____________________________________ Size and Shape of Pupil: ______________________________
Other Areas of Dullness: ______________________________  Light Reaction  Accommodation
Special Tests EOM:
 Rebound Tenderness: Rovsing’s / Blumberg  Paresis  Nystagmus
 Costovertebral Tenderness  Saccades  Oculomotor Ataxia
 Shifting Dullness  Diplopia  Other: _____________________
 Psoas Sign CN V
 Murphy’s Sign  Ophthalmic  Maxillary
 Mandibular  Corneal Reflex
Male Genitalia  Jaw Clench
 Penile Lesions:____________________________________ CN VII
 Scrotal Swelling:___________________________________  Eyebrow Elevation  Forehead Wrinkling
Testicles  Eye Closure  Smiling
Size:_________  Tenderness:________________  Cheek Puffing
 Masses:___________________________________ CN VIII
 Varicocoele:_______________________________  Hear finger rub or whispered voice
 Hernia:__________________________________________ Rinne:___________________ Weber: ___________________
Transillumination: ___________________________________ CN IX, X
Palate and Uvula: ___________________________________
Extremities  Gag Reflex
 Amputation  Visible joint swelling CN XI
 Deformities Limitation of ROM  Shoulder Shrug (against resistance)
 Tenderness  Redness  Head Rotation (against resistance)
 Warmth  Edema CN XII (Tongue)
 Atrophy  Fasciculation
Capillary refill: __________________________________ Position with protrusion:______________________________
Peripheral pulses: _______________________________ Strength:___________________________________________
Motor Examination  Babinski
 Involuntary Movements
 Symmetry Sensory
 Atrophy  Pin prick
 Gait  Touch
 Spasticity  Two point discrimination
 Rigidity  Sense of Position
 Flaccidity  Vibratory Sense
 Clonus  Superficial sensation
 Carpopedal Spasm  Deep Sensation
 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 band
 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