HISTORY

Date and Time of History:

Date and Time of Admission:
Name:
Address:
Birthday:
Birth place:
Age:
Gender:
Marital Status:
Religion:
Occupation:
Handedness:
Source of History or Referral:
Reliability:
Chief Complaints:
________________________________________________________________
________________________________________________________________
History of Present Illness/Active Problem:
O:______________________________________________________________
L:_______________________________________________________________
D:______________________________________________________________
C:______________________________________________________________
A:_______________________________________________________________
R:______________________________________________________________
T:_______________________________________________________________
S:_______________________________________________________________
Past History:
Childhood Illnesses:
Adult Illnesses:
Medical:
Surgical:
Psychiatric:
Health Maintenance:
Immunizations:
Screening Tests:
Medications:
Present Illness:
Health Maintenance Information/ Past History:
Current Medications:
Allergies:
Childhood Illnesses:

Adult Illnesses:
Operation: (dates)
Other Hospitalization: (dates)
Current Health Status:
__Tobacco:
__Alcohol, Drugs & Related Substances:
__Exercise & Diet:
Immunizations:
__Screening Tests:
Safety Measures:
Family History: (Pedigree with age & cause of death)
__Diabetes:
__Heart Disease:
__Hypercholesterolemia:
__High BP:
__Stroke:
__Kidney Disease:
__TB:
__CA:
__Arthritis:
__Anemia:
__Allergies:
__Asthma:
__Headaches:
__Epilepsy:
__Mental Illness:
__Alcoholism:
__Drug Addiction:
__Death of Immediate Family Member: (if any)
Age & Cause:
Personal & Social History:
Occupation & Education:
Home Situation & Significant Others:
Daily Life:
Important Experiences:
Leisure Activities/Hobbies:
Religious Affiliation & Beliefs:
Review of Systems:
General:
__Weight Change:

__Fever/Chills:

__Dizziness:
__Fatigue:
Skin:
__Rashes:
__Lumps:
__Sores:
__Moles:
__Itching:

__Night Sweats
__Others:
__Dryness:
__Color Change:
__Changes in Hair or Nails:
__Skin Disorder/CA:
__Others

Head:
__Headache:
__Head Injury
__Dizziness/ Lightheadedness:
Eyes:
__Vision:
__Glasses or CL:
__Last Examination:
__Pain:
__Redness:
__Excessive Tearing:
__Cataracts

__Double Vision:
__Blurred Vision:
__Spots:
__Specks:
__Flashing Lights
__Glaucoma:
__Others:

Ears:
__Hearing:
__Tinnitus:
__Vertigo:

__Earaches:
__Infection:
__Discharge

Nose & Sinuses:

__Frequent Cold:
__Nasal Stuffiness:
__Discharge:
__Others:

__Itching:
__Nosebleeds:
__Sinus Problems:

Mouth & Throat:

__Teeth & Gums:
__Dentures (if any):
__Hoarseness:
Last Dental Examination:

__Dry Mouth:
__Sore Throat ():
__Others:

Neck:
__Lumps:
__Goiter:
__Others:

__Pain:
__Stiffness:

Breast:
__Lumps:
__Pain or Discomfort:

__Nipple Discharge:
__Others:

Self-Examination Practices:
Respiratory:
__Cough:
__Sputum (c, qty):
__Hemoptysis:
__Dyspnea:
__Wheezing:
__Asthma:
Last Chest X-ray:

__Bronchitis:
__Emphysema:
__Pneumonia:
__TB:
__Pleurisy:
__Others:

Cardiac:
__Heart Trouble:
__Palpitations:
__High BP:
__Dyspnea:
__Rheumatic Fever:
__Orthopnea:
__Heart Murmurs:
__PND:
__Chest Pain/Discomfort:
__Edema:
Past ECG or other test results:
Gastrointestinal:
__Trouble Swallowing:
__Heartburn:
__Appetite:
__Nausea:
__Vomiting:
__Regurgitation:
__Vomiting of Blood:
__Indigestion:
__Frequency of Bowel Movement:
__Color & Size of Stools:
__Change in Bowel Habits:
__Rectal Bleeding or Black Tarry Stools:
__Hemorrhoids:
__Constipation:
__Diarrhea:
__Abdominal Pain:
__Food Intolerance:
__Excessive Belching or Passing of Gas:
__Jaundice:
__Hepatitis
__Liver or Gallbladder Trouble:
__Others:
Urinary:
__Frequency:
__Polyuria:
__Nocturia:
__Burning or Pain:
__Hematuria:
__Urgency:

__Hesitancy:
__Dribbling:
__Incontinence:
__UTI:
__Stones:
__Others:

Genital:
Male:

__Hernias:
__Discharge From or Sores on the Penis:
__Testicular Pain or Masses:
__History of STD & treatments:
__Sexual Preference, Interest, Function & Satisfaction:
__Birth Control Methods, Condom Use & Problems:
__Exposure to HIV Infection:
Female:
__Age at Menarche:
__Regularity:
Frequency & Duration of Periods:
Amount of Bleeding:
Bleeding (amount, between periods or after intercourse, last menstrual period):
__Dysmenorrhea, Premenstrual Tension:
__Menopause (age, symptoms, postmenopausal bleeding):
__Discharge:
__Itching:
__Sores:
__Lumps:
__STDs and Treatment:
__# of Pregnancies:
__# of Deliveries:
__# of Abortions (spontaneous & Induced):
__Complications of Pregnancy:
__Birth Control Methods:
__Sexual preference, interest, function, satisfaction:
__Problems (including dyspareunia):
__Exposture to HIV infection:
Peripheral Vascular:
__Intermittent Claudication:
__Varicose Veins:

__Leg Cramps:
__Past Clots in Veins:

Musculoskeletal: (describe location & symptoms)

__Muscle or Joint Pains:
__Stiffness:
__Arthritis:
__Gout:
__Backache:
Neurologic:
__Fainting:
__Blackouts:
__Seizures:
__Weakness:
__Paralysis:
__Stroke:
__Sleep Disorder:
__Others:
__Numbness or Loss of Sensation:
__Tingling of pins & needles:
__Tremor or other involuntary movements:

Hematologic:
__Anemia:
__Past transfusions & rxns:
Endocrine:
__Thyroid trouble:
__Excessive sweating:
__Excessive thirst or hunger:
Psychiatric:
__Nervousness:
__Mood Disorder:

__Easy bruising/ bleeding:

__Pica:
__Heat or cold intolerance:
__Diabetes:
__Polyuria:
__Tension:
__Substance abuse:

PHYSICAL EXAMINATION:
GENERAL:
General appearance:
Temperature (oral/rectal):
Respiratory:
a. rate:_______/min
b. rhythm: __________
Blood pressure: __________mmHg
If abnormal:
a. Lying: __________mmHg
b. Sitting: __________mmHg
c. Standing: __________mmHg
RUA:__________; LUA:__________
RLL:__________; LLL:__________
Body size:
Height: __________
Weight: __________
a. ideal body weight:
b. % of ideal body weight:
Body habitus:
Hair:
Skin:
Nails:
Other:
Head, Ears, Nose:
Cranial/orbital bruit:
Pinnae/canals/drums:
Nose:
Other:
Eyes:
External eyes:
Fundi:

Pupil:
Other:
Oral Cavity:
Teeth/gums/oral mucosa:
Tongue:
Tonsils/pharynx:
Parotid enlargement:
Other:
Neck:
Inspection
Carotid bruit: (R)___________; (L)__________
Venous hum:
Thyroid:
Other:
Nodes:
Lymph nodes:
Chest:
Inspection:
Chest structure:
Chest motion:
Retractions:
Palpation:
Tracheal position:
Vocal fremitus:
Tactile fremitus:
Percussion:
Resonant:
Hyperresonant:
Dull:
Flat:
Auscultation:
Crackles:
Rhonci:
Wheezes:
Stridor:
Breast:
Mass:
Nipple/Areola:
Cardiovascular System:
Jugular venous pressure:
Jugular venous pulsations:

Clinical CVP:
Apex beat location:
PMI location:
Carotid pulse:
Heaves:
Thrills:
Lifts:
Pulmonary artery pulsation:
First heart sound:
Second heart sound:
Third heart sound:
Fourth heart sound:
Click:
Murmur:
Rubs:
Pulsus alterans:
Peripheral pulses/bruits:
(scale pulses 0-4; normal 3)
Edema:
Right leg
1
2
Left leg
1
Abdomen:
Inspection:
Auscultation:
Bowel Sounds:
Bruits/ Rubs:
Palpation: pain/ tenderness:
Ascites:
Liver: Auscultation:
Liver: shape/ size:
Spleen:
Inguinal canal:
Other:

3
2

4
3

Male Genitalia:
External male genitalia:
Female Genitalia:
Pelvic exam: (indicate sites of abnormality)
a. external genitalia
b. vagina
c. cervix
d. uterus
e. adnexa
f. pap test: done: _____ not done:_____
Other:

Rectal Examination:
Rectal: Inspection/tone/hemorrhoids/masses:
Prostate:
Other:

NEUROLOGIC EXAMINATION
Mental Status Examination:
A. General behavior and appearance:
B. Stream of talk:
C. Mood & affective responses:
D. Content of thought:
E. Intellectual Capacity:
F. Sensorium
1. consciousness
2. attention span
3. orientation to time, place and person
4. memory, recent & remote
5. calculation
6. fund of information
7. insight, judgment and planning
Speech:
A. Dysphonia:
B. Dysarthria: (phonemes, vowels, consonants & labials CN VII; gutturals CN
X; linguals CN XII)
C. Dysprosody:
D. Dysphaia:
Head and Face:
A. Inspection:
1. impression, gestalt, motility & expression
2. shape & symmetry
3. hair of scalp, eyebrows, & beard
4. ptosis, palpebral fissures, relation of iris to lids, papillary size,
interorbital distance
5. contours & proportions of nose, mouth, chin & ears
B. Palpate
Lumps:
Depressions or tenderness:
Temporal arteries:
Infants:
fontanelles & sutures:
occipitofrontal circumference:
C. Percuss:
Sinuses & mastoid processes

D. Auscultate: (bruits)
Neck vessels:
Eyes:
Temples:
Mastoid processes:
E. Transilluminate:
Sinuses:
Infants:
Cranial Nerves:
A. Optic Group: II, III, IV & VI
1. Inspect:
a. width of palpebral fissures
b. relation of limbus to lid margins
c. interorbital distance
d. en- or exophthalmos
2. Visual functions:
a. acuity (central fields): newsprint or Snellen chart
b. peripheral fields:
- confrontation
3. Pupillary Light Reflexes:
Size of Pupils:
4. Ophthalmoscopy (findings):
5. Ocular motility:
a. fields of gaze
b. miosis during convergence
c. cover-uncover test
d. nystagmus
d. other eye movements:
B. Branchiomotor group and tongue: V, VII, IX,
X, XI and XII
1. V: masseter & temporalis bulk
2. VII:
a. forehead wrinkiling, eyelid closure, mouth retraction, whistling or
puffing out cheeks, wrinkling of skin over nck
b. labial articulations
c. Chvosteks sign:
3. IX & X:
a. phonation & articulation (labial, lingual, & palatal):
b. swallowing, gag reflex & palatal elevation:
4. XII:
a. lingual articulations:
b. midline & lateral tongue protrusion:
c. tongue atrophy & fasciculations:
5. XI:
a. sternocleidomastoid & trapezius contours:
b. head movement & shoulder shrug:
6. 100 repetitive movements if with history of pathologic fatigability:

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7. assess rate, regularity & depth of breathing:

C. Special Sensory Group
1. Olfaction (I):
2. Taste (VII): salt or sugar
3. Hearing (VIII)
a. otoscopy
b. threshold & acuity: (conversational speech, tuning fork, ticking watch
or finger rustling)
c. air-bone conduction test of Rhine & vertex lateralizing test of Weber
d. bilateral stimuli using finger rustling (if w/ history of cerebral lesion)
e. audiopalpebral reflex: (infants & uncooperative patients)
D. Somatic Sensation of the Face:
1. corneal reflex (V-VII arc):
2. light touch over trigeminal area:
3. temperature discrimination over trigeminal area:
4. pain perception over trigeminal area:
5. buccal mucosal sensation (in selected patients):
Somatic Motor Systems:
A. Inspection:
1. gait testing: (free walking, toe & heel walking, tandem walking, deep
knee bend; child: hope & run)
2. posture, general activity level, tremors & other involuntary movement:
3. assess somatotype or body gesalt
4. observe size & contour of muscles: (atrophy or hypertrophy, body
asymmetry, joint malalignments, fasciculations, tremors & involuntary
movement)
5. lesions: (neurocutaneous stigmate)
B. Palpation: (atrophic, hypertrophic, tender or spastic)
C. Strength testing:
1. shoulder girdle:
2. upper extremities: (biceps, triceps, wrist dorsiflexors, grip; strength of
finger abduction & extension)
3. abdominal muscles: (sit-up)
4. lower extremities: (hip flexors, abductors & adductors; knee flexors, foot
dorsiflexors, invertors & evertors)
* grading scale:
0 paralyzed
1 severe weakness
2 moderate weakness
3 minimal weakness
4 normal
D. Muscle tone: (passive movements of joints to test for spasticity, clonus, rigidity
or hypotonus)
E. Muscle stretch (deep) reflexes)
1. jaw jerk (V afferent & efferent)
2. biceps reflex (C5-C6)
3. triceps reflex (C7-C8)

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4. finger flexion reflex (C7-T1)

5. quadriceps reflex or knee jerk (L2-L4)
6. hamstring reflex (L5-S1)
7. triceps surae reflex or ankle jerk (L5, S1-S3)
8. toe flexion reflex (S1-S2)
F. Percussion: (thenar eminence for percussion myotonia; myotonic grip)
G. Skin-muscle (superficial reflexes)
1. abdominal skin-muscle reflexes:
a. T8-T9 upper quadrants
b. T11-T12 lower quadrants
c. Beevors sign (umbilical migration)
2. cremasteric reflex (L1-afferent; L2-efferent)
3. anal pucker (S4-S5); bulbocavernosus reflex
4. extensor toe sign or Babinski sign (S1-afferent, L5, S1-S2-efferent)
H. Cerebellar system:
1. finger-to-nose; rebound & rapid alternating hand movements:
2. heel-to-knee:
I. Nerve root stretching tests:
1. leg raising tests (disc or low-back disease is suspected):
a. straight-knee leg raising test (Laseagues sign):
b. bent-knee leg raising test (Kernigs sign);
2. suspected meningeal irritation:
a. nuchal rigidity & concomitant leg flexion (Brudzinskis sign):
b. leg raising tests:
Somatic sensory system:
A. Superficial sensory modalities:
1. light touch over hands, trunk & feet
2. temperature discrimination over hands, trunk & feet
3. pain perception over hands, trunk & feet
B. Deep sensory modalities:
1. vibration perception at knuckles, fingernails, malleoli of ankles and
toenails
2. position sense of fingers & toes (use 4th digits)
3. stereognosis
4. Romberg (swaying) test
5. directional scratch test
C. Determine distributional pattern of any sensory loss: dermatomal, peripheral
nerve(s), central pathway, or nonorganic:
Cerebral Functions:
A. MSE
B. If MSE suggests cerebral lesion, test for:
a. agraphognosia
b. finger agnosia
c. poor 2-pt discrimination
d. right-left disorientation

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e. atopognosia
f. tactile, auditory & visual inattention to bilateral stimuli
g. tactile inattention to simultaneous ipsilateral stimulation of face-hand &
foot-hand
C. Halstead-Reitan cognitive, constructional & performance tests for cerebral
dysfunction
Case Summary or Clinical Impression:
________________________________________________________________
________________________________________________________________
________________________________________________________________

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