Davao Medical School Foundation, Inc

ARTS AND SCIENCE OF MEDICINE 2

RATING SCALE FOR APPROACH TO SYMPTOM:

ABDOMINAL PAIN

Name of Student: _______________________________________ Roll # ______ Date:

_______

Legend: 1 = DONE COMPLETELY/ O= NOT DONE/ DONE INCORRECTLY/

DONE CORRECTLY DONE INCOMPLETELY
DONE NOT DONE/ REMARKS
COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
A. ESTABLISHING RAPPORT AND DONE
ASKS FOR CHIEF COMPLAINT INCOMPLETELY
1. Greets the patient politely

2. Introduces self

3. Asks for the identifying data:

NAME, AGE, MARITAL
STATUS, OCCUPATION,
RELIGION, ADDRESS

4. Tells the patient the purpose of

the interview

5. Asks the patient’s consent for

interview

6. Asks the CHIEF COMPLAINT

B. ABDOMINAL PAIN. ASKS ABOUTH THE FOLLOWING:

7. Onset of ABDOMINAL PAIN
“When is the first time you feel the
abdominal pain”
8. Location of ABDOMINAL
PAIN
“ Can you point to me the location/part
in your abdomen where the pain is?”
9. Duration of ABDOMINAL
PAIN
e.g: During an episode of
ABDOMINAL PAIN, how long
will it last? Is it persistent?

10. Character of ABDOMINAL

PAIN
Can you describe to me the
abdominal pain? E.g: Is it burning?
Stabbing? Colicky? Or vague
11. Aggravating factors

Is there any factor, which can

exacerbate the ABDOMINAL
PAIN?
12. Alleviating Factors

e.g: Did you take any

medication for ABDOMINAL
 PAIN? Or what medication did
you take? Or What factors can
relieve your ABDOMINAL
PAIN?

13. Associated symptoms

e.g: Aside from ABDOMINAL

PAIN what other symptoms do
you have?

DONE NOT DONE/ REMARKS

COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
DONE
INCOMPLETELY
14. Timing

How often do you have your

ABDOMNAL PAIN? When
does it occur? E.g After meal?
If you skip meal?

15. Severity

Can you tell me how severe is

the abdominal pain, if 1 is a
very minimal pain and 10 is the
most painful, where is your
pain right now?

C. Explains to the patient the

possible cause of the
symptoms

D. Shares and explains the

diagnostic and therapeutic
plan

E. Allows the patient to decide

on the diagnostic and
treatment option

F. Summarizes the plan to the

patient

G. Asks the patients for further

clarification and questions

H. Thanks the patient

Name and Signature of Preceptor____________________________________

Date__________

Updated and Revised by: Dr. Gladys Ogatis-Sermon

Compiled by: Dr. Claire Frances Miyake

 Davao Medical School Foundation, Inc
ARTS AND SCIENCE OF MEDICINE 2

RATING SCALE FOR APPROACH TO SYMPTOM:

COUGH

Name of Student: _______________________________________ Roll # ______ Date:

_______

Legend: 1 = DONE COMPLETELY/ O= NOT DONE/ DONE INCORRECTLY/

DONE CORRECTLY DONE INCOMPLETELY
DONE NOT DONE/ REMARKS
COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
A. ESTABLISHING RAPPORT AND DONE
ASKS FOR CHIEF COMPLAINT INCOMPLETELY
1. Greets the patient politely

2. Introduces self

3. Asks for the identifying data:

NAME, AGE, MARITAL
STATUS, OCCUPATION,
RELIGION, ADDRESS

4. Tells the patient the purpose of

the interview

5. Asks the patient’s consent for

interview

6. Asks the CHIEF COMPLAINT

B. COUGH. ASKS ABOUTH THE FOLLOWING:

7. Onset of COUGH

8. Duration of COUGH

e.g: During an episode of

cough, how long will it last? Is
it persistent?

9. Is your cough productive(with

phlegm) or dry?

10. Character of PHLEGM if

productive

Asks about color and

consistency of phlegm? If it is
blood streaked or none blood
streaked.

11. Aggravating factors

Is there any factor, which can

exacerbate your cough?

12. Alleviating Factors

e.g: Did you take any

medication for cough? Or what
 medication did you take? Or
What factors can relieve your
cough?

DONE NOT DONE/ REMARKS

COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
DONE
INCOMPLETELY
13. Associated symptoms

e.g: Aside from cough what

other symptoms do you have?

14. Timing

How often do you have your

cough? Or Does your cough
occur in specific time of the
day?

15. Severity

e.g: Is your cough

progressive? Or do you
already have difficulty of
breathing(dyspnea

C. Explains to the patient the

possible cause of the
symptoms

D. Shares and explains the

diagnostic and therapeutic
plan

E. Allows the patient to decide

on the diagnostic and
treatment option

F. Summarizes the plan to the

patient

G. Asks the patients for further

clarification and questions

H. Thanks the patient

Name and Signature of Preceptor____________________________________

Date__________

Updated and Revised by: Dr. Gladys Ogatis-Sermon

Compiled by: Dr. Claire Frances Miyake

 Davao Medical School Foundation, Inc
ARTS AND SCIENCE OF MEDICINE 2

RATING SCALE FOR APPROACH TO SYMPTOM:

FEVER

Name of Student: _______________________________________ Roll # ______ Date:

_______

Legend: 1 = DONE COMPLETELY/ O= NOT DONE/ DONE INCORRECTLY/

DONE CORRECTLY DONE INCOMPLETELY
DONE NOT DONE/ REMARKS
COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
A. ESTABLISHING RAPPORT AND DONE
ASKS FOR CHIEF COMPLAINT INCOMPLETELY
1. Greets the patient politely

2. Introduces self

3. Asks for the identifying data:

NAME, MARITAL STATUS,
AGE, OCCUPATION,
RELIGION, ADDRESS

4. Tells the patient the purpose of

the interview

5. Asks the patient’s consent for

interview

6. Asks the CHIEF COMPLAINT

B. FEVER. ASKS ABOUTH THE FOLLOWING:

7. Onset of fever

8. Duration of fever
e.g: How long is the duration of
fever before it subsides?

9. Character of fever
e.g: “Can you describe your
fever? Like is it occurring the
whole day? Or it is on and off?
NOTE: know what it means by
INTERMITTENT, REMITTENT,
PERSISTENT, RELAPSING

10. Alleviating Factors

e.g: Did you take any

medication for fever? Or what
medication did you take?

11. Associated symptoms

e.g: Aside from fever what

other symptoms do you have?

12. Timing
 Can you describe the timing of
your fever? Or Does your fever
occur in specific time of the
day?

13. Severity

e.g: Do you really feel hot or

not that much?

DONE NOT DONE/ REMARKS

COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
DONE
INCOMPLETELY
14. Documentation of Fever

Did you check your

temperature with a
thermometer? If yes, tell me
the range

15. Have you had a history of

travel? If yes, where?

16. What infectious disease is

present in your locality?

C. Explains to the patient the

possible cause of the
symptoms

D. Shares and explains the

diagnostic and therapeutic
plan

E. Allows the patient to decide

on the diagnostic and
treatment option

F. Summarizes the plan to the

patient

G. Asks the patients for further

clarification and questions

H. Thanks the patient

Name and Signature of Preceptor____________________________________

Date__________

Updated and Revised by: Dr. Gladys Ogatis-Sermon

Compiled by: Dr. Claire Frances Miyake

 Davao Medical School Foundation, Inc
ARTS AND SCIENCE OF MEDICINE 2

RATING SCALE FOR APPROACH TO SYMPTOM:

HEADACHE

Name of Student: _______________________________________ Roll # ______ Date:

_______

Legend: 1 = DONE COMPLETELY/ O= NOT DONE/ DONE INCORRECTLY/

DONE CORRECTLY DONE INCOMPLETELY
DONE NOT DONE/ REMARKS
COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
A. ESTABLISHING RAPPORT AND DONE
ASKS FOR CHIEF COMPLAINT INCOMPLETELY
1. Greets the patient politely

2. Introduces self

3. Asks for the identifying data:

NAME, AGE, MARITAL
STATUS, OCCUPATION,
RELIGION, ADDRESS

4. Tells the patient the purpose of

the interview

5. Asks the patient’s consent for

interview

6. Asks the CHIEF COMPLAINT

B. HEADACHE. ASKS ABOUTH THE FOLLOWING:

7. Onset of HEADACHE

8. Location: Where exactly the

part of the head with pain?
Can you point it?

9. Duration of HEADACHE
e.g: During an episode of
HEADACHE, how long will it
last? Is it persistent?

10. Character of HEADACHE

11. Aggravating factors

Is there any factor, which can

exacerbate the HEADACHE?

12. Alleviating Factors

e.g: Did you take any

medication for HEADACHE?
Or what medication did you
take? Or What factors can
relieve your HEADACHE?

13. Associated symptoms

 e.g: Aside from HEADACHE
what other symptoms do you
have?

DONE NOT DONE/ REMARKS

COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
DONE
INCOMPLETELY
14. Timing

When do you usually have

your headache?

15. Severity

Can you tell me how severe is

the HEADACHE, if 1 is a very
minimal pain and 10 is the
most painful, where is your
pain right now?

C. Explains to the patient the

possible cause of the
symptoms

D. Shares and explains the

diagnostic and therapeutic
plan

E. Allows the patient to decide

on the diagnostic and
treatment option

F. Summarizes the plan to the

patient

G. Asks the patients for further

clarification and questions

H. Thanks the patient

Name and Signature of Preceptor____________________________________

Date__________

Updated and Revised by: Dr. Gladys Ogatis-Sermon

Compiled by: Dr. Claire Frances Miyake

 Davao Medical School Foundation, Inc
ARTS AND SCIENCE OF MEDICINE 2

RATING SCALE FOR APPROACH TO SYMPTOM:

LOOSE BOWEL MOVEMENT

Name of Student: _______________________________________ Roll # ______ Date:

_______

Legend: 1 = DONE COMPLETELY/ O= NOT DONE/ DONE INCORRECTLY/

DONE CORRECTLY DONE INCOMPLETELY
DONE NOT DONE/ REMARKS
COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
A. ESTABLISHING RAPPORT AND DONE
ASKS FOR CHIEF COMPLAINT INCOMPLETELY
1. Greets the patient politely

2. Introduces self

3. Asks for the identifying data:

NAME, AGE, MARITAL
STATUS,OCCUPATION,
RELIGION, ADDRESS

4. Tells the patient the purpose of

the interview

5. Asks the patient’s consent for

interview

6. Asks the CHIEF COMPLAINT

B. LBM. ASKS ABOUTH THE FOLLOWING:

7. Onset of LBM

8. Duration of LBM
e.g: During an episode of LBM,
how long will it last? Is it
persistent?
9. Character of STOOL
Asks about color and
consistency (WATERY, SOFT)
of STOOL? If it is blood
streaked or none blood
streaked.
10. Aggravating factors

Is there any factor, which can

exacerbate the LBM?

11. Alleviating Factors

e.g: Did you take any

medication for LBM? Or what
medication did you take? Or
What factors can relieve your
LBM?

12. Associated symptoms

e.g: Aside from LBM what

 other symptoms do you have?

DONE NOT DONE/ REMARKS

COMPLETELY/ DONE
CORRECTLY INCORRECTLY/
DONE
INCOMPLETELY
13. Timing

How often do you have your

LBM?

14. Severity

e.g: How many times do you

have the LBM for a day? Can
you approximate the amount, a
glass? A teaspoon?

15. Do you have history of travel?

16. What did you eat prior to LBM?

C. Explains to the patient the

possible cause of the
symptoms

D. Shares and explains the

diagnostic and therapeutic
plan

E. Allows the patient to decide

on the diagnostic and
treatment option

F. Summarizes the plan to the

patient

G. Asks the patients for further

clarification and questions

H. Thanks the patient

Name and Signature of Preceptor____________________________________

Date__________

Updated and Revised by: Dr. Gladys Ogatis-Sermon

Compiled by: Dr. Claire Frances Miyake