PATIENT PROFILE

Date of Interview:________________________________________
Ward:__________________________________________________
Admission Date:_________________________________________
Source and Reliability:____________________________________

Life History
Name:____________________________________________
Sex:

male

female

Age:_______________________

Birthdate:_______________________________

Address:________________________________________________________________
No. of years residing:______________________________________________________
Previous address:____________________________________________________________
Reason for transfer:__________________________________________________________
Birthplace/Place of origin:______________________________________________________
Religion:__________________________________________
Educational Attainment: Elementary

undergraduate graduate

High School undergraduate graduate

College

undergraduate graduate

Course:_______________________

Others:______________________________________________
Civil Status:

single

married/living with partner

divorced

widowed

Years married: _______________________________

Occupation and Employment History

Present work:________________________________________ For how many years:__________________
Previous work:_______________________________________ For how many years:__________________
Income:__________________________________________________________
Source of income (aside from work):___________________________________
Usual Expenses:___________________________________________________

Living Environment
Family Composition/Position in the family: ______________________________________
Living with who/whom: _____________________________________________________
Number of rooms:_____________________

# of storey: 1 floor

2 floors

3 floors

others:______

How many people in the house:__________________________________________

Type of house: wood

concrete

Water supply (for drinking):

Nawasa

others:
water station/mineral water

deep well

Garbage disposal: collected by a truck, how often:________________________________________

burned
compost pit

others: _________________________________

Habits and Description of average day

Hobbies and interest: _________________________________________________________________________
Health Practices: ____________________________________________________________________________
good

eats less

no appetite

After illness/at present: good

eats less

no appetite

Appetite before illness:

Favorite food:_______________________________________________________________________________
Religious Restrictions:________________________________________________________________________
Diet/restrictions:_____________________________________________________________________________

How many hours of sleep per day (usual):_________________________________________________________

Quality of sleep: good

wakes at the middle of the night

Problem falling asleep: yes

no

Routine before sleeping:

drinking milk

difficult initiating sleep after waking up

exercising/working out

others:________________________

Exercise:

yes

no

How often (per week):

once twice thrice everyday every weekend

occasional

What kind of exercise:

jogging

stretching

working out

cardio workout

gym

running

others:______________________________________

Bowel movement:

everyday

every other day

3x a week

Usual color of stool:

black

yellowish

greenish

brown

watery

with blood (gross)

Characteristics of stool: hard

aerobics

others:

Urinary Frequency (estimated number of urination a day):____________________________________________

Characteristics:

yellowish

clear dark yellow

with pain during urination

without pain during urination

nocturia

difficulty in initiating urination

with blood

others:______________________________________________

Use of tobacco/smoking:

yes

no

Since when:_________________________________________________
How many sticks/day:_________________________________________

Alcohol Intake:

yes

no

When:

everyday

twice a week thrice a week occasional

How much:_____________________________________________________

Caffeine intake:

yes

no

How often:

everyday twice a week thrice a week others:

Illegal drug Intake: yes

no

What drug:_________________________________________________
How much:_________________________________________________

Current Medications (taken at home)

Drug

Dose/Route

Frequency

Duration

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

**Character,

Location & Radiation, Intensity or Severity, Timing, Alleviating & Relieving Factors, Associated Symptoms

PAST HEALTH MAINTENANCE HISTORY

1. Childhood disease
Age illness was acquired

Treatment/Regimen done

Chicken pox
Measles
Mumps
Tuberculosis
Malaria
Dengue
Influenza
Gastroenteritis

2. Allergies
Food:___________________________________________________________________________
Drugs/Medications:________________________________________________________________
Clothes:_________________________________________________________________________
Environment:_____________________________________________________________________

3. Surgeries/Hospitalization
Hospital

Procedure/Diagnosis

Date of confinement/
Length of stay

4. Immunization

complete

incomplete

cannot recall

Date Given

Number of dose received

BCG
Hepatitis B
OPV
MMR
DPT
Tetanus Toxoid

5. Major Illness
Illness/disease

Diagnosed when/since when

6. Accidents
Hospital

Date of confinement/
Length of stay

Diagnosis

Treatment/Work ups

7. Menstrual History

Menarche: ____________________________________________________________________

If your menstrual periods are regular, periods start every: _________________days

If your menstrual periods are irregular, periods start every: _______ to _______days

Duration of bleeding: _________ days

Interval between menstruation:____________________________________________________

Amount of bleeding (how many pads): ______________________________________________

Does bleeding or spotting occur between periods?

Is pain associated with periods?

If yes, is it:

yes

before menses

yes

no

no
during menses

both

Last Menstrual Period: __________________________________________________________

Post-menopausal Bleeding:

yes

no

8. Obstetric History

Gravida ____ Parity ____ (Term____ Preterm ____ Abortion ____ Living ____)
Delivery of the Baby

Year
(Planned
or Not?)

Living/
Abortion

Duration of
Pregnancy
(term/preterm)

Hrs. of
Labor

Manner of
delivery (if CS,
state reason)

Child
Where and
assisted by
whom

Feto-maternal
complication

Sex

Birth
weight

Present
Health

Family Planning Methods

Pills

Brand:_______________________

# of years used:___________________

Brand:_______________________

# of years used:___________________

Condom
Withdrawal
Injection

Duration of effect:________________________________________
Calendar method
Bilateral tubal ligation

Vasectomy

Others:__________________________________________________________________


Date of
Prenatal
Check-up

Prenatal Summary

Maternal
Weight

Danger Signs of
Pregnancy

Blood
Pressure

Pelvic/Cervical
Examination

Fetal
Movement

Fundal
Height
(cm)

Fetal
Heart
Rate

Fetal
Position
(Leopolds
Maneuver)

**Danger Signs: N/V, Severe Headaches, Blurry Vision, Swelling of the head or face, Fever, Diarrhea, Regular contractions,
Vaginal bleeding, Gush of fluid from vagina, Persistent back pain, Pelvic/Abdominal pain

How was the pregnancy confirmed? _______________________________________________________

Assessment (Date and Time taken:__________________________________________)

o

Height_______________ Weight_____________ BMI____________

Temperature __________HR ________________ BP ____________ RR___________

Fundic height:___________cm

Leopolds Maneuver/Fetal Position:__________________________________________

9. Gynecological History

Infection:

UTI

PICOS Endometriosis

Venereal Warts

Genital Herpes

others:__________________________________________________________

If yes, when and how was it treated?_______________________________________________________

10. Sexual History

Age of first contact/sex:__________________________________________________________

Number of partners:_____________________________________________________________

Frequency of sex/contact (per week):_______________________________________________

Signs and symptoms associated during/after contact or sex:

pain during intercourse

post coital bleeding

others:_________________________

FAMILY HISTORY
Name

Age

Postition in the Family

Illness

REVIEW OF SYSTEMS

General
Fever___ Fatigue___ Sweating___ Weight Loss/Gain___ Weakness___
Skin
Color___ Texture___ Itching___ Rashes___ Changes in hair/nails___
Eyes
Visual Impairment___ Redness___ Tearing___ Pain___ Double Vision___ Discharge___ Trauma___
Ears
Hearing Loss___ Otalgia___ Discharge___ Tinnitus___
Nose, Throat, Mouth
Nasal Obstruction___ Discharge___ Abnormal Olfaction/Anosmia___ Epistaxis___
Frequent colds/cough___ Dysphagia___ Odynophagia___ Change in Voice___ Neck Mass___ Toothache___
Dental Caries___ Gum Bleeding___ Ulceration___ Congenital Deformities___
Respiratory
Cough/Sputum___ Difficulty of Breathing___ Wheezing (Asthma)___ PTB Exposure___ Hemoptysis___
Cardiovascular
Palpitation___ Syncope___ Chest pain___ Edema___ Hypertension___ Orthopnea___ Dyspnea___
Gastrointestinal
Dysphagia___ Nausea___ Vomiting___ Appetite___ Abdominal Pain___ Melena___ Jaundice___ Bleeding___
Indigestion___ Heartburn___ Hematemesis___
Fatty Food Intolerance___ Stool Frequency/Character___ Hemorrhoids___
Abdominal Distention___ Hernia
Urinary
Pain___ Volume___ Retention___ Bleeding___ Stream___ Polyuria___ Nocturia___ Stones___ Infection___
Hesistancy___ Urgency___ Change in Color___ Frequency___ Dribbling___
GenitoReproductive (Male)
Discharge___ Pain___ Libido___ Sexual Difficulties___
GenitoReproductive (Female)
Menarche___ LMP___ PMP___ Menses: Regular___ Duration___ Amount___
Post-coital bleeding___ Contraceptive Use___ No. of pregnancies___ Complications___
Live Births___ Heaviest Baby ___lbs PID___
Breast
Nipples___ Lump___ Pain___ Discharge___
Extremities
Cyanosis___ Clubbing___ Edema___ Varicosity___ Ulcers___ Claudication___
Hematopoietic System
Excessive bleeding/bruising___ Anemia___ Pica___
Nervous System
Headache___ Tremor___ Fainting Spells___ Seizures___ Dizziness/Vertigo___
Head Trauma___ Sensory perversions___ Movement problems ___
Language/learning problem ___
MusculoSkeletal
Joint Stiffness___ Pain___ Swelling___ Muscle Weakness___
Endocrine System
Heat/Cold Intolerance___ Thyroid Problems___ Neck Surgery/Irridiation___ DM Indicators___
Psychiatric
Mood Swings___ Behavioral Changes___ Anxiety___ Depression___

PHYSICAL ASSESSMENT
Time/Date Done:___________________________

Vital Signs
Temp_________ Radial Pulse_________ Apical Pulse_________ RR_________ BP_________

General Survey
Sensorium____________________________________ Distress_______________________________________
Facial Expression/Mood/Affect__________________________________________________________________
Speech/Articulation___________________________________________________________________________
Appears Age Stated______________ Acute or Chronically Ill__________________ Skin Color_______________
Any Physical Deformities______________________________________________________________________
Mobility_______________________ Normal Gait_________________ Needs Assistance___________________
Use of Assistance Device_______________________ What?_________________________________________
Nutritional Status_________________ Weight_____________ Height: ______________ BMI _______________
Hygiene and Grooming________________________________________________________________________

Skin
General Color: Pallor

Jaundice

Flushed

Cyanotic

Texture:

Smooth

Rough

Others____________________

Turgor:

Good

Fair

Poor

Moisture:

Dry

Wet/Clammy

Oily

Ecchymoses

Hematoma

Hemorrhages: Petechiae

Location________________________________________________________________
Lesions:______________ Location______________________ Measurement________________
Head
Hair:

Fine

Coarse

Dry

Normal

Scalp:

Clean

Dandruff

Lice

Lesions________________________________

Eyes:

Visual acuity

__________________(left)

Near-sighted

Far-sighted

Alopecia

___________________(right)
Astigmatism

Corrective lens_________________________________________________________________
Conjuctiva____________________________ Sclera___________________________________
Pupils (left)
(right)

_______mm

Reactive

Consensual Reflex

_______mm

Reactive

Consensual Reflex

EOM___________________ Nystagmus________________ Visual Fields__________________

Ptosis__________________ Exophthalmos______________ Tension_____________________
Fundoscopy___________________________________________________________________
Ears
Lesions of the external ear_____________________________ Location_________________________________
Discharge____________________ Tympanic Membrane____________________ Mastoids_________________

Nose
Patency______________________ Discharge_________________________ Blockage____________________
Septum_________________________________ Sinus Tenderness____________________________________

Mouth
Lips:

Pallor

Cyanosis

Dryness/Cracks

Lesions__________________________

Teeth:

Complete

Missing

Dentures

Caries

Gums:

Pinkish

Pale

Bleeding

Tenderness

Tongue: Uvula Position____________________________ Check Structures: Midline? _____________________

Salivary Glands: _____________________________________________________________________________
Throat:

Enlarged Tonsils

Post-nasal Drip

Neck
Any CLAD? ________________________________________________________________________________
Thyroid____________________________________________________________________________________
Stiffness______________________________________ Masses_______________________________________
Lymph Nodes_______________________________________________________________________________

Breast
Masses_________________________________________ Discharge__________________________________

Chest & Lungs

Anterior Thoracic Cage Configuration____________________________________________________________
Posterior Thoracic Cage Configuration____________________________________________________________
Spinous Process________________________________ Percussion___________________________________
Breathing Pattern:

Effortless

Tachypnea

Hyperpnea

Bradypnea

Dyspnea

Orthopnea

Chest Expansion:

Symmetrical

Vocal Fremitus:

None

Assymetrical
Egophony

Apnea

(right/left)___________
Bronchophony

Whispered Pectoriloquy

Tactile Fremitus_____________________________________________________________________________
Percuss Lung Field___________________________________________________________________________
Breath Sounds:

Clear

Equal

Crackles

Wheezes

Location________________________________________________________________
Pericordial Area:

Heart Sounds:

Flat

Bulging

Normodynamic

Hyperdynamic

Tenderness Thrill

PMI at _______________________________________

S1

S3

S2

Rhythm________________________ Murmur (where?)__________________________

Abdomen
Dilated Veins

Skin:

Striae

Scars

Rashes

Location______________________________________________________________________
Flat Globular

Configuration:
Bowel Sound:

Protuberant

Scaphoid

Symmetrical

Normal or Hyperactive or Hypoactive

*presence of bowel sound per quadrant

Abdominal Pain____________________ Location______________________________ Scale_______________

Bruit:

Absent

Present

Percussion:

Tympanitic

Hypertympanitic

Fluid Wave Test

Shifting Dullness Test

Muscle Guarding

Direct Tenderness

Palpation:

Location______________________________________
Dull
Rebound Tenderness

Liver______________________________________________________________________________________
Kidney_____________________________________________________________________________________
Spleen_____________________________________________________________________________________

MusculoSkeletal and Extremities

Nail:

Pink

Joints: Redness

Pale

Cyanosis

Warmth

Crepitation

Inflammation

Clubbing

CRT________

Swelling at __________________________________________________________________________
Tenderness at ________________________________________________________________________
Full ROM ____________________________________________________________________________
Decreased ROM at ____________________________________________________________________
Legs:

Varus

Valgus

Gluteal Folds:

Symmetrical

Assymetrical

Edema:

None

Non-Pitting

Pitting [ +1 (<2mm)

+2 (2-4mm)

+3 (5-7mm)

+4 (>8mm)]

Location is at __________________________________________________________________
Muscle Size:

Equal

Atrophy at _____________________________________________________

Tone:

Normal

Hypertonic

MMT Grading System

Flaccid

Fasciculation

Tics

Tremors

5 move against resistance

4 move with some resistance
3 move against gravity not with resistance
2 move in joint but not against gravity
1 move but barely detectable or not normal strength

Peripheral Vascular System (0, +1, +2, +3)

Left

Pulse Site

Right

Radial
Brachial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial

Neurosensory
Level of Consiousness
DTR
Babinski
Balance
Strength
Sensation
Seizure Precaution
Stereognosis
Extinction
Graphesthesia
Two Point Discrimination

CN 1: __________________________________________ CN 2: __________________________________________
CN 3: __________________________________________ CN 4: ___________________________________________
CN 5: __________________________________________ CN 6: ___________________________________________
CN 7: __________________________________________ CN 8: ___________________________________________
CN 9: __________________________________________ CN 10: __________________________________________
CN 11: _________________________________________ CN 12: __________________________________________
Cerebellar:

fingers-to-nose

Romberg

tandem walk

stand on one foot

rapid hand alternation

Deep Tendon Reflex:

Biceps:___________________________________ Patellar: ________________________________________
Triceps: __________________________________ Achilles: ________________________________________
Brachioradialis: ____________________________ Cremasteric: ____________________________________