Source:
Reliability:
Time of Evaluation:
GENERAL DATA
 Patient initials/ full name:
 Age:
 Gender:
 Nationality:
 Religion:
 Occupation:
 Marital Status:
 Current Residence:
 Place of birth:
 Date of birth:
 Number of admissions: (Date & time)
 Institution:
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CHIEF COMPLAINT
 One or more symptoms or concerns cause
the patient to seek care.
HISTORY OF PRESENT ILLNESS
 Amplify the chief complaint while
describing how each symptom developed in
a chronological fashion (OLD CARTS) Onset,
Location, Duration, Character,
Aggravating/ Alleviating Factors,
Radiation, and Timing,
 Location
 Quality
 Quantity or severity (Pain score)
 Timing, onset, duration, frequency
 Setting in which symptom occurs
 Aggravating/relieving factors
 Pertinent positives/pertinent
negatives
 medication use, name (generic and brand,
dose, route, frequency of use, total # of
tablets/capsules taken)
 Any other signs/symptoms.
 Skin lesions:

PAST MEDICAL HISTORY
 Childhood illness
 Immunizations (BCG, DPT, POLIO,
MMR)- COVID vaccine.
 Known childhood illnesses, year
diagnosed, maintenance
medications, compliance to meds,
any known complications (MMR,
whopping cough, chickenpox,
rheumatic fever, scarlet fever, polio)
 History of admissions
 Adult illness
 Medical
 Known medical illnesses,
year diagnosed,
maintenance medications,
compliance to meds, any
known complications: (
DM, ASTHMA, HTN,
RENAL PROBLEMSPROBLEMA SA BATO,
CANCER)
Screening tests/Annual
medical exam findings
(CBC, U/A, X-RAY, LIPID
PROFILE)
Admission
History of Blood
transfusion/donation
(Blood type)
Surgical:
 Accidents, injuries.
Obstetric/Gynecologic:
 Age at menarche.
 regularity,
 frequency
 duration of periods
 amount of bleeding;
bleeding between periods
or after intercourse
 last menstrual period
 dysmenorrhea
 premenstrual tension
 Vaginal discharge, itching,
sores, lumps, sexually
transmitted infections and
treatments.
 Number of pregnancies,
number and type of
deliveries, number of
abortions (spontaneous
and induced),
complications of
pregnancy, (GTPAL)
 No. of children
 birth-control methods/
FAMILY PLANNING
 Sexual preference,
interest, function,
satisfaction, any
problems, including
dyspareunia. Concerns
about HIV infection.
Psychiatric illnesses
PERSONAL AND SOCIAL HISTORY
 Smoking history
 Alcohol use
 Illicit drug use
 Educational level
 Occupation
 Personal interests
 Lifestyle
 Travel
 Exercise habits
 Dietary practices
 Personal Hygiene
 Sleeping Habits
 Sexual orientation and practices
 Current household members and health
status
 Marital relationship status if any
 Home safety, garbage and waste disposal
 Food and water supply
 Electrical supply
FAMILY HISTORY
 Heredo-familial diseases in the maternal
and paternal side
 Age, health, cause of death, comorbidities,
medications of parents, siblings and
grandparents.
 Presence of hypertension, diabetes,
asthma, cancer, early cardiovascular
deaths- cardiac arrest, psychiatric illnesses
in the family
REVIEW OF SYSTEMS
System
General: State of consciousness
(conscious, lethargic, stuporous,
comatose), coherent or incoherent,
cooperative, ambulatory, nutritional
status, severity of illness (Stable,
toxic, moribound), febrile, emotional
(in respiratory distress
Skin: Rashes, lumps, sores, itching,
dryness, color change, changes in hair
or nails
Head: Headache, head injury,
dizziness, lightheadedness
Eyes: Vision, glasses or contact
lenses, last examination, pain,
redness, excessive tearing, double
vision, blurred vision, spots,
specks, flashing lights, glaucoma,
cataracts
Ears: Hearing, tinnitus, vertigo,
earaches, infection discharge. If
hearing is decreased, use or non-use
of hearing
aids
Throat (or mouth and pharynx):
Condition of teeth, gums, bleeding
gums, dentures if any and how they
fit, last dental examination, sore
tongue, dry mouth, frequent sore
throats, hoarseness.
Neck: Lumps, "swollen glands",
goiter, pain, or stiffness in the neck.
Breasts: Lumps, pain or discomfort,
nipple discharge, self-examination
practices.
Respiratory: Cough, sputum (color,
quantity), hemoptysis, dyspnea,
wheezing, pleurisy, last chest x-ray,
asthma, bronchitis, emphysema,
pneumonia, and tuberculosis.
Cardiovascular: Heart trouble, high
blood pressure, rheumatic fever,
heart murmurs, chest pain or
discomfort, palpitations, dyspnea,
orthopnea, paroxysmal nocturnal
Comment
dyspnea, edema, past
electrocardiographic or other heart
test results
Gastrointestinal: Trouble swallowing,
heartburn, appetite, vomiting,
nausea, regular bowel movements,
color and size of stools, change in
bowel habits, rectal bleeding or black
or tarry stools, hemorrhoids,
constipation, diarrhea, abdominal
pain food intolerance, excessive
belching or passing of gas, jaundice,
liver or gallbladder trouble, hepatitis.
Urinary: Frequency of urination,
polyuria, nocturia, urgency, burning
or pain on urination, hematuria,
urinary infections, kidney stones,
incontinence
Genital (Male): Hernias, discharge
from or sores on the penis, testicular
pain or masses, scrotal pain or
swelling,
history
of
sexually
transmitted infections and their
treatments. Sexual habits, interest,
function, satisfaction, birth control
methods, condom use, and problems.
Concerns about HIV infection.
Genital (Female): Age at menarche;
regularity, frequency, and duration of
periods; amount of bleeding,
bleeding between periods or after
intercourse, last menstrual period:
dysmenorrhea, premenstrual
tension; age at menopause,
menopausal symptoms,
postmenopausal bleeding. If the
patient was born before 1971
exposure to diethylstilbestrol (DES)
from maternal use during pregnancy,
vaginal discharge, itching, sores,
lumps, sexually transmitted diseases
and treatments. Number of
pregnancies, number and type of
deliveries, number of abortions
(spontaneous and induced);
complications of pregnancy; birth
control methods. Sexual preference,
interest, function, satisfaction, any
problems inducing dyspareunia,
exposure to HIV infection
Peripheral Vascular: Intermittent
claudication, leg cramps, varicose
veins, past clots in the veins
Musculoskeletal: Muscle or joint
pains,
stiffness, arthritis, gout and
backache. If present, describe
location of affected joints or
muscles, presence of any swelling
redness, pain, tenderness, stiffness,
weakness, or limitation of motion or
activity; include timing of symptoms
(for example, morning or evening),
duration, and any history of trauma
Hematologic: Anemia, easy bruising
or bleeding, past transfusions and/or
transfusion reactions.
Endocrine: Thyroid trouble, heat or
cold intolerance, excessive sweating,
excessive thirst or hunger, polyuria,
change in glove or
shoe size.
Psychiatric: Nervousness, tension,
mood, including depression; memory
change, suicide attempts, if relevant.
Neurologic: Fainting, blackouts,
seizures, weakness, paralysis, number
or loss of sensation, tingling or pins
and needles sensation, tremors or
other involuntary movements
PHYSICAL EXAMINATION
General Survey
1. Observes for signs of distress; alters approach if
patient is distressed.
2. Observes apparent age, gender, and race. 3. Notes
facial characteristics, symmetry of features,
expression, and condition and color of skin.
4. Notes body type and posture.
5. Greets patient with handshake to assess muscle
strength (if culturally appropriate).
6. Observes gait and any abnormal movements (or
ability to move about in bed).
7. Listens to speech pattern, pace, quality, tone,
vocabulary, and sentence structure.
8. Obtains interpreter if there is a language barrier.
9. Assesses general mental state and affect.
10. Observes dress, grooming, and hygiene.
11. Measures vital signs.
12. Measures height and weight.
a.
Adults: Calculates BMI from height and weight
measurement.
b.
Infants and children < 2 years: Height—
positions supine with knees extended; also measures
head circumference.
c.
Infants: Weighs without clothing;
d. Older children: Weighs in underwear.
13. For children, plots height and weight on growth
chart and evaluates trends.
Vital Signs
 Blood pressure (mmHg)
 Pulse rate (bpm)
 Respiratory rate (cpm)
 Temperature (ºC)
 O2 Saturation (%)
Mental Status Examination