HISTORY AND PHYSICAL EXAMINATION Past Medical History:

Current Medications:
Date of Interview: ______________________________ Generic Brand Dosage Frequency Purpose
Time of History: _______________________________
Informant: ____________________________________
Relationship to the Patient: ______________________
% Reliability: _________
Immunizations:
General Data:  BCG  DPT  Polio  Hepa B
Patient’s Name: _____________________________ Others: ________________________________________
Age: ______ Sex: _______ Marital Status: ________ Allergies:
Address: _________________________________________________ Food: ___________________________________
Birthday: ________________ Birthplace: _______________________ Medications: ______________________________
Nationality: ______________ Religion: _________________________ Pollen/Animals/Others: ______________________
Occupation: __________________________ Childhood Illness:
 rheumatic fever  polio
Date of Admission: ______________________  chicken pox  measles
Time of Admission: ______________________  mumps
No. of times admitted at OM: ______________ others: ______________________________
Adult Illness:
Chief Complaint: ________________________________________ Illness Age Date of Diagnosis
Hypertension
History of Present Illness: Stroke
Onset: _______________________________ Renal
Duration: _____________________________ Asthma
Frequency: ___________________________ TB
Setting at which the Symptom Occurred: _______________________
DM
_______________________________________________________
Cardiac
Manifestations: ___________________________________________
Location: ________________________________________ GI
Precipitating Factors: _______________________________ STD
Quality: _________________________________________ Others
Radiation: _______________________________________
Severity: ________________________________________ Surgical Procedures:
Aggravating Factors: ______________________________________ Date: _______________________________
Alleviating Factors: ________________________________________ Type of Operation: _____________________
Previous Treatment for the Problem: __________________________ Purpose: _____________________________
Associated Signs and Symptoms: _____________________________ Previous Hospitalizations:
________________________________________________________ Date Cause Hospital Treatment
Pertinent Positives and Negatives: ____________________________
________________________________________________________
Additional Notes: __________________________________________
________________________________________________________
________________________________________________________ Screening Tests:
Test Date Result
Tuberculin test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
Xray/CT Scan/MRI
Others

Menstrual and Obstetric History:

LMP: ____________ PMP: _______________
Age of menarche: ____________ Period: regular/irregular
Character of flow: ____________
Duration of period (range): ____________
No. of pads used per day: ____________
PMS: ___________________________________________________
Age of Menopause: _______
Age of 1st coitus: ________ No. of sexual partners: __________
History of post-coital bleeding, pelvic infection, dyspareunia?
Birth control methods used:
Artificial Natural
 condom  rhythm method
 pills  withdrawal
 spermicidal  abstinence
Others: ____________________________________
Length of time used: _________
Complications: ______________________________
Gravidity: ______ Parity: _______ Previous place of residence: ____________
OB Index: ________ Term ___________________________________
________ Preterm Type of residence: ___________________
________ Abortions/Miscarriages No. of rooms: _______________________
________ Living Children No. of occupants: ____________________
Date of Birth Sex Manner of Delivery Relationship to occupants: __________________________
______________________ ____________________ ________________________________________________
______________________ ____________________ Source of Drinking Water: ___________________________
______________________ ____________________ Garbage Disposal: _________________________________
Fecal Disposal: ___________________________________
OB Hx: G _ P_ (T-P-A-L) Pet/s: __________________________________________
G1: When _________, NSD or CS d/t _________, delivered by Personally gives bath to pets? Y/N
_________, where _________, M/F, weight _________, fetomaternal General State of neighborhood: _____________________
complications _____________________, present status __________.
Review of Systems:
Constitutional:
Family History:  Fever  Weight gain/loss
Family Age Health/ Age & Date Cause of  Chills  Fatigue
Member Diseases of Dx death Skin:
Father  Rashes  Itching
Mother  Lumps  Dryness
Others  Color Change  Changes in Nails
Hair:
 Baldness  Excess Hair
Head:
 Headache  Dizziness
Medical Problems for any blood-relative  Lightheadedness  Trauma
 Syncope  Tenderness
Relationship to Px Age & Date of Dx
Eyes:
Cancer  Pain  Redness
Hypertension  Double Vision  Blurred Vision
Diabetes  Use of Glass/Lenses  Photalgia
Tuberculosis  Lacrimation
Heart Disease Ears:
Stoke  Hearing Problem  Earache
Kidney Disease  Discharge (color/consistency) ____________
Arthritis  Tinnitus  Vertigo
Blood Disorder Nose and Sinuses:
Asthma  Epistaxis  Nasal stuffiness
Epilepsy  Discharge (color/consistency): ____________
 Itching
Mental Disorder
Mouth and Throat:
 Use of dentures  Mouth sores
 Bleeding Gums  Toothache
Personal and Social History:  Sore throat  Hoarseness
No. of years married: ______  Dysphagia
Health Status of Spouse: ______________ Neck:
No. of Children: _______  Pain  Stiffness
Health Status of Children: ___________________________________  Lump
Highest Educational Attainment: ______________________________ Breast:
Occupational History: _______________________________________  Pain  Discharge
________________________________________________________  Lumps  Periodic Exam
________________________________________________________
Occupational Hazards: _____________________________________ Respiratory:
Smoking Habits:  Cough  Sputum (color/quantity) ________
 non-smoker  smoker ex-smoker  Hemoptysis  Dysnea
No. of sticks/packs per day: _________  Wheezing
Year started: ______ Year quitted: ______ Cardiovascular:
Alcohol Consumption  Chest Pain  Palpitations
 never  occasionally  Orthopnea  Edema
 daily  weekly  Cyanosis  Paroxysmal 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  Diarrhea
Coffee/tea/soda intake: _______________  Hematochezia  Excessive belching/passing of gas
Nutrient Supplement:: ________________ Renal:
OTC: _______________________  Dysuria  Polyuria
Prohibited Drugs: _____________  Nocturia  Gross Hematuria
Substance Abuse: _____________  Incontinence  Urinary Retention
Exercise: ___________________________________  Urinary Urgency  Tea-Colored Urine
Regularity of Sleep: ___________________________ In Males:
Habits/hobbies: ______________________________  Reduced caliber of force of stream
Sources of Stress: ___________________________  Hesitancy
Coping Strategies: ___________________________  Dribbling
Living Conditions: Genitalia:
No. of years in current residence: _______  Pain  Swelling
 Discharge (characteristics): ________________ Fundoscopic
 Ulcers  Itching Red orange reflex: ______________
Peripheral vascular: Disc: ________________________
 Leg cramps  Varicose veins Macula: _____________________
Muskuloskeletal: Blood vessels: _________________
 Muscle weakness  Stiffness
 Backache  Joint swelling Ears:
 Muscle pain  Join Pain Symmetry: _______________
Neurologic:  Swelling: ______________________________
 Paralysis  Numbness  Redness: ______________________________
 Tremors  Seizures  Discharge: ______________________________
 Memory Loss  Tenderness: _____________________________
Hematologic:  Hearing Impairments: _______________________
 Easy bruising  Bleeding  Presence of Hearing Aid: _____________________
 Pallor Weber Test: ______________________________
Endocrine Rinne Test: (R) AC __________ BC ___________
 Polydypsia  Polyphagia (L) AC __________ BC ___________
 Heat/cold intolerance  Excessive sweating
Psychiatric: Nose:
 Nervousness  Depression Symmetry: ___________________________
 Anxiety  Hallucinations Frontal, maxillary sinus tenderness: ____________________
Obstruction: __________________________
PHYSICAL EXAMINATION Congestion: __________________________
Lesions: _____________________________
General Survey: Exudates: ____________________________
Mood: ______________ Inflammation: _________________________
Distress/ Unusual Position: _____________
Cooperative/ Non-cooperative Throat:
Irritable/agitated/pleasant Lips: _____________________
Coherent: _________ Teeth/dentures: _______________________
Oriented to time and space: _______ Gums: _______________________________
Personal Hygiene: _______________ Tongue: _____________________________
Level of Consciousness: _______________ Pharynx:
Height: ____________  Lesions: ______________  Erythema: _____________
Weight: ____________  Exudates: _____________ Tonsillar Size: _________
BMI: ______________
Neck:
Vital Signs: Symmetry: _________________________
Temperature: ________  Oral  Axillary  Rectal Limitation of ROM: __________________
Respiration: _________  Normal  Labored Tenderness: _________________________
Pulse: _____________  Regular  R. Irreg.  Irr. irreg. JVD: ______________________________
Blood Pressure: _______  Lying  Sitting  Standing Lymph nodes: ________________________
Size: _____________
Head: Mobility: ___________
Trauma: ________________________________ Tenderness: _____________
Size: ______________ Shape: _____________ Borders: ________________
Tenderness: __________________________________ Consistency: _____________
Condition of hair and scalp: _______________________________ Thyroid cartilage: _____________ Cricoid cartilage: ______________
Symmetry: ___________________________ Thyroid gland: ________________
Masses: _____________________________
Chest and Lungs
Eyes: Inspection
Visual acuity: Comfort and Breathing Pattern: _____________________
Far: (R) ________ (L) ________ Shape of the Chest: ______________________________
Near: (R) ________ (L) ________ Chest Movement: ________________________________
Visual Fields (H test): ___________________  Use of Accessory Muscles of Breathing: ______________
Accommodation: _______________________  Deformities of Asymmetry: _________________________
Test of confrontation: ___________________  A/N Retraction of Interspaces on Inspiration: ___________
Conjunctiva:  Impairment of Respiratory Movement: ________________
Color: ____________________________ Color of Patient (Lips & Nail Bed): ___________________
Discharge: ________________________ Palpation
Sclerae:  Tender Areas: ___________________________________
Color: ____________________________ Respiratory Expansion (10th rib): Symmetry  Yes  No
Discharge: ________________________ Tactile Fremitus: Symmetry 
Cornea: Increased Decreased Absent 
Clarity: ___________________________ Percussion: ____________________________________
Corneal Arcus: _____________________ Auscultation
Lids: ______________ Iris: ________________ Breath Sounds: _________________________________
Position of eyes in orbits: ______________________________  Bronchophony  Whispered Petoriloquy
Pupil:  Egophony

Size: (R) __________ (L) ___________ Heart:

Shape: ____________ Symmetry: ______________ Inspection
Accommodation: _______________ Precordial bulge or heave: __________________
Light reflex test (PERLA): ________________ PMI: __________________________
EOM: ________________________ Palpation
Visual Field: ____________________________ PMI: __________________________
Direct Reaction: ____________ Consensual Reaction: ____________ Thrill: _____
 Location: _________________
Timing in Cardiac Cycle (S/D): ______________ NEUROLOGICAL EXAMINATION
Mode of Extension/Transmission: ____________
 Friction Rub: ___________________ Mental Status Examination
Percussion: Cardiac Borders A. Awareness
Right (cm) ICS/MSL Left (cm) Orientation
5th Name:  Season  Date  Day  Month  Year
4th Name:  Hospital  Floor  Town  State  Country
3rd Level of consciousness:
- 2nd B. Speech (Normal, dysphasia, dysarthria, dysphonia)
C. Language
Auscultation
Name:  Pencil  Watch
S1 (M-loud, T-split): ___________________
Repeat: “ No ifs  ands  or buts”
S2 (A,P-loud, P-split I): ___________________
D. General Knowledge
S3: _________________________
Knowledge of current events, vocabulary
Murmurs/Accessory Heart Sounds:
(Historical events, 5 last presidents, 5 largest cities)
Location: __________________ Timing: _______________
E. Memory
Quality: ___________________ Pitch: ________________
Immediate, recent, remote
Intensity: __________________ Radiation: _____________
F. Registration (Retention and recall)
Identify:  Object 1  Object 2  Object 3
Breast:
Attention and Calculation
Symmetry: _____________
(100-7…):  93  86  79  72  65
 Dimpling/Skin Retraction: _____________________
Recall
 Swelling: ____________________
Recall:  Object 1  Object 2  Object 3
 Discoloration (Skin changes): _________________
G. Reasoning
 Orange Peel Effect: _________________
Judgment, Insight, abstraction (interpretation of proverbs)
Position and Characteristic of Nipple: _________________
H. Object recognition
 Gynecomastia (Male): _________________
Agnosia (Visual, tactile, auditory, autotopagnosia, anosognosia)
 Mass:
Praxis (Ideomotor, Ideational)
Location: _____________________________
Perception (Delusion, Hallucination, illusion, astereognosis,
Size: ___________ Consistency: _________________
agraphestesia)
Tenderness: ______________ Mobility: _____________
I. Follows Command
Borders: _________________
 Take this paper.  Fold it in half.  Place it on the table.
 Obey written command.
Abdomen:
 Write a sentence.
Inspection
 Copy a design.
 Irregular Contours: ____________ Scars
Total: _____
 Discoloration: ________________
 Bulges: _____________________
Cranial Nerve Examination
Shape: _____________________
CN I
 Striae: ______________________
 Identify odorant
Distance of umbilicus from xiphoid process: __________
CN II
Abdominal Girth: __________________
Visual acuity: ________ Visual field: _________
Auscultation
Fundoscopy: ____________________________________________
Bowel Sounds: Frequency: ___________ Character: ____________
CN III, IV, VI
 Bruit: ___________________
Size and Shape of Pupil: __________________
 Venous Hum: ______________
 Light Reaction  Accommodation
 Friction Rub: _______________
EOM:
Percussion
 Paresis  Nystagmus
Liver Span: _______________ Normal: 6-12 cm in (R)MCL
 Saccades  Oculomotor Ataxia
Splenic Dullness: ______________
 Diplopia  Other _____________
Other Areas of Dullness: _______________
CN V
Special Tests
 Ophthalmic  Maxillary
 Rebound Tenderness: Rovsing’s, Blumberg
 Mandibular  Corneal Reflex
 Costovertebral Tenderness
 Jaw Clench
 Shifting Dullness
CN VII
 Psoas Sign
 Eyebrow Elevation  Forehead Wrinkling
 Murphy’s Sign
 Eye Closure  Smiling
 Cheek Puffing
Male Genitalia:
CN VIII
 Penile Lesions: _______________
 Hear finger rub or whispered voice
 Scrotal Swelling: _______________________
Rinne: ____________ Weber: ____________
Testicles
CN IX, X
Size: ________  Tenderness: ___________
Palate and Uvula: _____________
 Masses: ______________
 Gag Reflex
 Varicocoele: _________________
CN XI
 Hernia: ________________
 Shoulder Shrug (against resistance)
Transillumination: ________________
 Head Rotation (against resistance)
CN XII (Tongue)
Extremities:
 Atrophy  Fasciculation
Amputation Visible joint swelling
Position with protrusion: _________
Deformities Limitation of ROM
Strength: __________
Tenderness Redness
Warmth Edema
Motor Examination
 Involuntary Movements
Capillary refill: ______________
 Symmetry
Peripheral pulses: ___________
 Atrophy
 Gait
 Paresis  Sense of Position
 Paralysis  Vibratory Sense
 Spasticity  Superficial sensation
 Rigidity  Deep Sensation
 Flaccidity
 Clonus
 Carpopedal Spasm
 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 bend
 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
 Babinski

Sensory
 Pin prick
 Touch
Two point discrimination