PERSONAL Hx:

I. Prenatal Hx: Pt. was born to a _____ y.o. G P ( - - - - ) mother who ( ) smoke at least ___ sticks per day,
( ) drinks alcoholic beverages at least ____ glasses/bottles/gallons of _______ per drinking session during the whole
course of pregnancy. ( ) prenatal check-up started from ___ mos AOG to ____ mos AOG at _____________ conducted by a
_____. She received ( ) TT__ vaccine, ( ) vit, ( ) FeSo4, taken for ___ days/wks/mos. ( ) Maternal illness such as
fever, cough & colds, UTI & others _________ during ____ mos AOG for ____days/weeks/months. ( ) Medication, self
treated/prescribed meds of ________________ for ___________ illness taken at ____mos AOG for ___days/wks/mos. ( ) Hx
of exposure to radiation, (
) abortion, (
) hypogastric pain, (
) persistent uterine contractions, (
) vaginal
spotting/bleeding, ( ) watery vaginal d/c.
II. Birth Hx: Pt. was delivered pre-/full-/post- term w/ ___ AOG via _______ assisted by a ________ at _____________ in
____________ presentation w/ ______ hrs/days of active labor. Umbilical cord was cut using a __________ sterilized/preboiled/ soaked with __________ & sloughed off for ___days/wks. ( ) complications observed at the umbilical area such
as foul-smelling/yellowish color/erythema/pus/bloody/watery d/c. Umbilical stump was cleaned every _____ using a
__________________.
III. Neonatal Hx: Pt. was pinkish/pale/bluish/yellowish with a _______ cry, ( ) weak, ( ) vigorous movements. ( )
Dyspnea, (
) Fever/Convulsions, (
) bleeding. (
) First stools [Meconium], ___________ in color, ____________ in
consistency w/ __________ odor after ____ hrs and ( ) urine after _____ hrs of life.
IV. Feeding Pattern: Pt. was breastfed/bottlefed _____ hrs after birth, every ____ hrs/min with ____min duration on
each breast. Pt. was bottle fed at ____mos., supplemental feeding / solid food was introduced at ____ mos consisting of
___________________________. ( ) Vit given at ____ mos, ____mL OD/BID.
24 HOUR DIET RECALL:
I: Before onset of illness:
Breakfast: _______________________
Lunch: __________________________
Dinner: _________________________
Snack: __________________________
V. GROWTH and DEVELOPMENT

VI. IMMUNIZATION HISTORY

BCG

Hep B (Doses____)

PCV

Measles

Meningococcal

DPT ( Doses___)

Hib (Doses___)

Flu
Date last dose:

Hepa A

HPV
(Doses_____)

MMR (Doses___)

Rotavirus
(Doses_______)

Varicella

Others

OPV/
(Doses___)

IPV

VII. PAST MEDICAL HISTORY (Put a

pertinent data)

if positive and X if negative on the appropriate box

and write on blank for

Other Illnesses: None Asthma Diabetes Blood disorder

Others:______________________________
Previous Hospitalization/ Surgery/ Blood Transfusion None Yes
If Yes: Specify (Year/Diagnosis) ______________________________________________________
Allergies/
Drug
Reactions:

None
Known
Yes,
Specify/
Reaction:_____________________________________
Menstrual & Gynecologic History: Not applicable
Menarche: ___yrs old, regular irregular interval, Duration ____day/s, Amount____pads/day
Dysmenorrhea
Medications taken prior to admission: None (Include home remedies, alternative medicine,
nonprescription medications & indicate amount given per day)

IX. FAMILY Hx:

Father: ____y.o., works as a _____________, apparently well/dx w/ ______________________________

Mother: ____y.o., works as a _____________, apparently well/dx w/ _____________________________
Siblings: ________ F, _____ M, all apparently well/ not ________________________________________
Thyroid Problems
Congenital heart disease
Hypertension
Renal Disease
Asthma
Blood Dyscrasia
Atopic Diseases
Cancer
Tuberculosis
Others______________
Diabetes

X. PSYCHOSOCIAL History
Pt. is a ____________, he/she lives with her/his ___________________________ in a ____ ( ) well ventilated bedroom
house made of ______________ materials situated along the __________,. Toilet is located inside/outside the house approx
____ meters away from the house. ( ) Electricity. Water for drinking is from a ______________ stored in a _____________ &
water for washing clothes & dishes is from a _______________________. Garbage is disposed through ___________________. (
) Dusts, carpet, pets, stuffed toys, cockroaches, mice, mosquitoes, bugs, insects. ( ) Stagnant water. Father is a
______________, ( ) smoker/alcohol bev drinker, earns a total income of P__________/month or P_________/day. Mother is
a ______________, ( ) smoker/alcohol bev drinker, earns a total income of P__________/month or P_________/day. He/She
interacts well/friendly towards other children, participates in school/household chores. They actively participates in
community activities & they are members of any religious / civic group __________________.

REVIEW OF SYSTEMS
General:
Skin:
HEENT:

UnremarkableWeight loss Weight Gain Fever Malaise loss of appetite

Others:___________________
Unremarkable Rash Unusual pigmentation Dryness Hirsutism Hair loss Nail Changes
Itching Others:___________________
Unremarkable Headache Head Injury Eye Pain Excessive Tearing Double vision Use of
glasses/ contact lenses Ear ache Ear discharge Hearing problems Nasal Stuffiness Frequent
colds Epistaxis Neck Stiffness Neck lumps Frequent sore Throat Hoarseness Gum
bleeding Excessive salivation Toothache Others:___________________

Respiratory:

Unremarkable Cough Shortness of breath Difficulty of breathing Wheezing hemoptysis

Sputum; color & quantity______________ Others:___________________

Cardiovascular:

Unremarkable Chest pain/ discomfort palpitationsheart murmurs cyanosisrheumatic fever

Others:__________________
UnremarkableTrouble swallowing Jaundice Abdominal pain Nausea Vomiting Diarrhea
Constipation Hematemesis Hematochezia Melena flatulence Others:___________________

Gastrointestinal:

Genito-Urinary:

Normal Dysuria Frequency Nocturia Polyuria Oliguria Discharge

Others:___________________

Muskuloskeletal:

Normal myalgia Joint pains/ stiffness limitation of movement swelling

Others:___________________
Normal Fainting Seizures Weakness Numbness Paralysis Anxiety
Others:__________________

Neuro/Psychiatric

PHYSICAL EXAMINATION
GENERAL SURVEY
Pt. was (conscious, lethargic, stuporous, comatose), ( ) sleepy, ( ) alert, ( ) coherent, ( ) oriented to
person, time & place, ________ nourished, ( ) groomed, _____morph, ( ) in cardio respiratory distress, ( )
febrile, ______ developed with the following vital signs & anthropometric measurements.
BP: __________ mmHg
Temp: _______ C

HR: ______ bpm

RR: ______ cpm

Actual
Weight:
_________
Ht/Length
HC
AC
CC
MUAC

Ideal
______

______
______
______
______

______

Percentile Rank
__________

Z Score
_____________

__________
_____________
________
__________
_____________
_________
__________
_____________
________
__________
_____________
________
__________
_____________
________

INTEGUMENT
SKIN: dry/moist, ( ) pale, _______ complexion, ( ) rashes, ( ) petechiae, ( ) active lesions, ( ) scars,
( ) hypo/hyper pigmentation, ( ) central/peripheral cyanosis, ( ) jaundice, ( ) edema
on____________.Others:___________________________

HEAD:

EYES:

EARS:

HAIR: short/long, straight/curly, black/brown, ( ) fine/coarse, ( ) intact, ( ) flag sign, ( ) nits/ lies
SCALP: ( ) lumps, ( )tenderness, ( ) scars, ( ) engorged veins, ( ) active lesions, ( ) dandruff
Skull: _____cephalic, temples ______depressed, ant fontanelle _______, post fontanelle_____________.
Eyebrows: ___symmetrical, ( ) fine, ( )black, ( )intact, ( ) scars or active lesions
Eyelashes: ( ) fine, ( ) black, ( ) oriented outwards
Eyelids: ( ) edema, ( ) ptosis, ( ) lidlag, ( ) sty
Conjunctiva: ( ) pale, ( ) pinkish, palpebral conjunctiva, ( ) hemorrhage
Sclera: ( ) anicteric, ( ) icteric, ( ) hemorrhage
Cornea: ( ) ulcerations, ( ) scars, ( ) opacities, ( ) arctus
Pupils: ( ) symmetrical, ____mm in diameter, ( ) reactive to direct & ( ) consensual light stimulation
EOM: ( ) intact/full
( ) symmetrical, ( ) discharges, ( ) active lesions, ( )impacted cerumen

NOSE: ( ) discharge _____________, ( ) abnormal configuration, ( ) septal deviation, ( ) epistaxis, ( ) flaring

MOUTH & THROAT:
Lips: ( ) dry/moist, ( ) pale/pinkish, ( )angular deviations, ( ) cold sores
Mucous membrane: ( ) moist/dry, ( ) bleeding, ( ) sores
Gums: ( ) pale/pinkish, ( ) bleeding
Teeth: #______upper, #_________lower, _____dental caries on________
Tongue: ( ) pinkish, ( ) ulceration, ( ) papillary atrophy, ( ) tremors upon protrusion
Throat: ( ) uvula at midline, ( ) inflammation
NECK: ( ) trachea at midline/deviated to R/L, ( ) thyroid gland palpable, ( ) thyroid gland moves w/
deglutition, ( ) engorged veins, ( ) visible pulsation, ( ) lymph nodes/ lymph adenopathy, ( ) firm/soft,
( ) mobile/not, approx _________in diameter.
BREASTS: ( ) symmetrical, ( ) nipples, ( ) nipple d/c __________, Tanner Stage __________
CHEST AND LUNGS:
Inspection:___ in shape, ___ symmetrical lung expansion, ___ lagging, ___ bulging, ___ retractions of
subcostals and intercostals
Palpation: ___ masses, ____ confirmed symmetrical lung expansion, ___ tactile fremitus
Percussion: ___ on all lung fields, dullness at ______, hyperresonant at _____.
Auscultation: ___ bronchovesicular breath sounds over all lung fields, ___ rales at _____, wheezing at
_____, cracles at ______, ___pleural friction rub.
ABDOMEN:
Inspection: ___flat, ___visible peristalsis, ___engorged veins, ___hypo/hyperpigmentation, ___visible
localized bulging, ___umbilicus
Palpation: ___soft, ___tenderness, liver ___palpable, spleen & kidney ___palpable, ___intraabdominal or
muscular masses: _______
Percussion: ___tympanitic in all regions, ___dullness at ___
Auscultation: ___normoactive bowel sounds, ___arterial bruit, ___ venous hum, ___peritoneal friction rub.
EXTREMITIES:
Inspection: ___equal length, ___deformities, ___lesions, ___edema, ___cyanosis, ___atrophy
Palpation: ___muscular tenderness
Radial Pulse ___
Popliteal Pulse ___
Dorsalis Pedis ___

BACK AND SPINE:

Inspection: ___abnormal deviation, ___retractions, ___bulging, ___muscle wasting
Palpation: ___paravertebral tenderness or mass
GENITALIA:
Inspection: ___lesion, ___discharges
RECTAL EXAM: _______________________________________

AUTONOMICS: _______________________________________
NEUROLOGIC EXAM
I.
MENTAL STATUS EXAM: ___active/inactive, ___quiet COMAFIC (consciousness, orientation, memory,
attentiveness, fond of knowledge, insight, calculation)
II.
CRANIAL NERVES:
CN I: (candies, coffee) ___anosmia
CN II & III: pupils ___mm in diameter, symmetrical, ___reactive to direct and ___consensual
light stimulation, ___peripheral vision (confrontation test), ___visual threat.
CN III, IV, VI: ___move eyes upward, downward, medially and laterally, ___dolls eye
CN V: ___sensory function to pain and touch, ___corneal reflex
CN VII: ___smile, ___able to frown, ___symmetrical upon crying
CN VIII: ___responsive to verbal stimuli
CN IX and X: ___gag reflex, ___able to swallow
CN XI: ___able to turn head to both sides against resistance, ___shrugs
CN XII: ___protrude tongue, ___deviation to L/R
III.
MOTOR: ___can flex and extend both ___upper & ___lower extrmities without limitation
Grade: 0 no contraction, 1 trace, 2 active w/o gravity, 3 moves w/ gravity, 4 against gravity
and resistance, 5 normal power
IV.
SENSORY: ___withdraws hand where pain stimulus is applied, ___ stereognosis, ___graphestesia,
___position sense, ___2 point discrimination, ___ Rombergs sign
V.
REFLEXES:
DTR 1. Achilles Reflex, 2. Patellar Reflex, 3. Biceps Reflex, 4. Triceps Reflex
Primitive - ___Moro reflex, ___Tonic neck reflex, ___Parachute reflex, ___Perez reflex
Pathologic - ___Babinski reflex, ___Chaddocks, ___Oppenheim, ___Gordons, ___Ankle clonus
VI.
CEREBELLUM: ___pronation-supination, ___finger to nose, ___heel to knee along shin
VII.
MENINGES: ___nuchal rigidity, ___Kernigs sign, ___Brudzinski sign
VIII.
ANS: ___excessive sweating, ___ urinary incontinence

ADMITTING DIAGNOSIS:
BASIS: