Date and Time:

Preceptor:

IDENTIFYING DATA
Name:
Sex:
Date of Birth: Age:
Address:
Religion:
Marital status:
Current occupation:
Source and Reliability:

If referral, previous doctor/source:

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

SYMPTOM: SYMPTOM:
ONSET: ONSET:
LOCATION: LOCATION:
DURATION: DURATION:
CHARACTER/QUALITY: CHARACTER/QUALITY:
AGGRAVATING: AGGRAVATING:

ALLEVIATING: ALLEVIATING:

RADIATION: RADIATION:
TIMING (am, pm etc.): TIMING (am, pm etc.):

SEVERITY AND QUANTITY: SEVERITY AND QUANTITY:

ASSOCIATED SYMPTOMS/MANIFESTATIONS: ASSOCIATED SYMPTOMS/MANIFESTATIONS:

MEDICATIONS TAKEN (name, dose, frequency): MEDICATIONS TAKEN (name, dose, frequency):
SYMPTOM: SYMPTOM:
ONSET: ONSET:
LOCATION: LOCATION:
DURATION: DURATION:
CHARACTER/QUALITY: CHARACTER/QUALITY:
AGGRAVATING: AGGRAVATING:

ALLEVIATING: ALLEVIATING:

RADIATION: RADIATION:
TIMING (am, pm etc.): TIMING (am, pm etc.):

SEVERITY AND QUANTITY: SEVERITY AND QUANTITY:

ASSOCIATED SYMPTOMS/MANIFESTATIONS: ASSOCIATED SYMPTOMS/MANIFESTATIONS:

MEDICATIONS TAKEN (name, dose, frequency): MEDICATIONS TAKEN (name, dose, frequency):

SYMPTOM: SYMPTOM:
ONSET: ONSET:
LOCATION: LOCATION:
DURATION: DURATION:
CHARACTER/QUALITY: CHARACTER/QUALITY:
AGGRAVATING: AGGRAVATING:

ALLEVIATING: ALLEVIATING:

RADIATION: RADIATION:
TIMING (am, pm etc.): TIMING (am, pm etc.):

SEVERITY AND QUANTITY: SEVERITY AND QUANTITY:

ASSOCIATED SYMPTOMS/MANIFESTATIONS: ASSOCIATED SYMPTOMS/MANIFESTATIONS:

MEDICATIONS TAKEN (name, dose, frequency): MEDICATIONS TAKEN (name, dose, frequency):

PERTINENT +/-
PAST MEDICAL HISTORY
CHILDHOOD ILLNESSES:
• Chicken pox
• Measles
• Mumps
• Allergies/Asthma (please specify):

• Others:

ADULT ILLNESSES:
Medical:

Surgical:

OB-Gyne:
Menarche:
Age during pregnancy:
GP Score:
TPAL Score:
Associated complications during pregnancy and childbirth (GDM, HTN etc.)

Contraception and family planning:

Psychiatric:

Immunizations:

Screening tests/monitoring:

FAMILY HISTORY
GENERAL SURVEY:
❏ Cancer
❏ Liver disease
❏ Kidney diseas
❏ HTN
❏ Diabetes
❏ Allergies/asthma
❏ Tuberculosis
PARENTS
Father: Mother:
Age died: Age died:
COD: COD:
Communicable/Familial diseases and Risk Communicable/Familial diseases and Risk
factors: factors:
❏ HTN ❏ HTN
❏ Diabetes ❏ Diabetes
❏ Cardiac problem (please specify) ❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify) ❏ Allergies/asthma (please specify)

❏ Smoker ❏ Smoker
❏ Alcoholic ❏ Alcoholic

SIBLINGS
Ranking:
Sibling:
Sibling: Age died:
Age died: COD:
COD: Communicable/Familial diseases and Risk
Communicable/Familial diseases and Risk factors:
factors: ❏ HTN
❏ HTN ❏ Diabetes
❏ Diabetes ❏ Cardiac problem (please specify)
❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify)

❏ Allergies/asthma (please specify)

❏ Smoker
❏ Smoker ❏ Alcoholic
❏ Alcoholic
Sibling: Sibling:
Age died: Age died:
COD: COD:
Communicable/Familial diseases and Risk Communicable/Familial diseases and Risk
factors: factors:
❏ HTN
❏ HTN
❏ Diabetes
❏ Diabetes ❏ Cardiac problem (please specify)
❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify)

❏ Allergies/asthma (please specify)

❏ Smoker ❏ Smoker
❏ Alcoholic ❏ Alcoholic

Sibling: Sibling:
Age died: Age died:
COD: COD:
Communicable/Familial diseases and Risk Communicable/Familial diseases and Risk
factors: factors:
❏ HTN
❏ HTN
❏ Diabetes
❏ Diabetes
❏ Cardiac problem (please specify)
❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify)

❏ Allergies/asthma (please specify)

❏ Smoker ❏ Smoker
❏ Alcoholic ❏ Alcoholic

IMMEDIATE FAMILY

Husband: ❏ Child:
Age died: Age died:
COD: COD:
Communicable/Familial diseases and Risk Communicable/Familial diseases and Risk
factors: factors:
❏ HTN ❏ HTN
❏ Diabetes ❏ Diabetes
❏ Cardiac problem (please specify) ❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify) ❏ Allergies/asthma (please specify)

❏ Smoker ❏ Smoker
❏ Alcoholic ❏ Alcoholic
 Child: Child:
Age died: Age died:
COD: COD:
Communicable/Familial diseases and Risk Communicable/Familial diseases and Risk
factors: factors:
❏ HTN ❏ HTN
❏ Diabetes ❏ Diabetes
❏ Cardiac problem (please specify) ❏ Cardiac problem (please specify)

❏ Allergies/asthma (please specify) ❏ Allergies/asthma (please specify)

❏ Smoker ❏ Smoker
❏ Alcoholic ❏ Alcoholic

PERSONAL AND SOCIAL HISTORY

House & Living arrangements:
Educational attainment:
Alcohol (frequency, qty etc):
Smoking (pack years):
Drug/s:
Interests:
Lifestyle:
Sexual orientation/practices:
Alternative health care practices:
Previous occupations:

Source of stress:

Financial support:
Exercise:

Diet: (# of meals in a day, composition, snacks)

Supplements:
REVIEW OF SYSTEMS

ADDITIONAL NOTES:
ADDITIONAL NOTES:
PHYSICAL EXAMINATION

1. General Survey (Observe)

o State of health __________________________________________
o Height ________________________________________________
o Built __________________________________________________
o Sexual development _____________________________________
o Patient’s weight _________________________________________
o Note posture, motor activity, and gait _________________________
o Dress, grooming, and personal hygiene ______________________
o Odors of the body or breath ________________________________
o Watch facial expressions __________________________________
o Note manner, affect, and reactions __________________________
o State of awareness or level of consciousness __________________

2. Vital Signs
o Blood pressure __________________________________________
o Pulse __________________________________________________
o Respiratory rate _________________________________________
o Body temperature ________________________________________

3. Skin
o Assess skin moisture, dryness, temp _________________________
o Lesions (location, distribution, arrangement, type, and color)
_______________________________________________________
o Inspect hair and nails _____________________________________
o Study hands ____________________________________________

4. Head, Eyes, Ears, Nose, Throat (HEENT)

o Examine hair, scalp, skull, and face __________________________
o Visual acuity ____________________________________________
o Screen the visual fields ____________________________________
o Position and alignment of eyes _____________________________
o Observe eyelids _________________________________________
o Inspect the sclera and conjunctiva ___________________________
o With oblique lighting, inspect each cornea, iris, and lens
______________________________________________________
o Compare the pupils, test their reactions to light _________________
_______________________________________________________
o Assess the extraocular movements __________________________
o Inspect the ocular fundi (ophthalmoscope) _____________________
o Inspect the auricles, canals, and drums _______________________
o Auditory acuity __________________________________________
o If acuity is diminished, check lateralization (weber test)
_______________________________________________________
o Compare air and bone conduction (rinne test) __________________
o Examine the external nose _________________________________
o Inspect the nasal mucosa, septum, turbinates __________________
o Palpate for tenderness of frontal, maxillary sinuses ______________
o Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils,
and pharynx ____________________________________________
o Assess the cranial nerves _________________________________

5. Neck
o Palpate cervical lymph nodes _______________________________
o Note unusual pulsations ___________________________________
o Feel any deviation of the trachea ____________________________
o Sound and effort of the patient’s breathing _____________________
o Palpate the thyroid gland __________________________________

6. Back
o Palpate the spine and muscles of the back ____________________
o Shoulder height for symmetry ______________________________

7. Posterior Thorax and Lungs

o Palpate the spine and muscles of the upper back _______________
_______________________________________________________
o Percuss the chest ________________________________________
o Identify level of diaphragmatic dullness on each side
_______________________________________________________
o Listen to the breath sounds ________________________________
o Identify any adventitious (or added) sounds ____________________

8. Breasts, Axillae, and Epitrochlear Nodes

o (W) inspect breasts with arms relaxed à elevated à pressed on her
hips ___________________________________________________
o Inspect the axillae ________________________________________
o Feel for the axillary nodes __________________________________
o Feel epitrochlear nodes ___________________________________

9. Anterior Thorax and Lungs

o Inspect, palpate, and percuss the chest ____________________________________
o Listen to the breath sounds ______________________________________________

10. Cardiovascular System

o Observe jugular venous pulsations ________________________________________
o Measure the jugular venous pressure (relate to sternal angle)
__________________________________________________________________
o Palpate the carotid pulsations ____________________________________________
o Listen for carotid bruits _________________________________________________
o Inspect and palpate the precordium _______________________________________
o Location, diameter, amplitude, and duration of the apical impulse
___________________________________________________________________
o Listen at each auscultatory area __________________________________________
o Listen at the apex and the lower sternal border with the bell
___________________________________________________________________
o Listen for the first and second heart sounds __________________________________
o Abnormal heart sounds or murmurs ________________________________________

11. Abdomen
o Percuss the abdomen __________________________________________________
o Palpate lightly, then deeply ______________________________________________
o Assess the liver and spleen by percussion and then palpation
___________________________________________________________________
o Feel the kidneys _______________________________________________________
o Palpate aorta and its pulsations ___________________________________________
o If kidney infection, percuss posteriorly over the costovertebral angles _____________

12. Lower Extremities

o Examine the legs ____________________________________________________
o With the patient supine:
o Palpate the femoral pulses _________________________________________
o Popliteal pulses __________________________________________________
o Palpate inguinal lymph nodes _______________________________________
o Lower extremity edema, discoloration, or ulcers _________________________
o Palpate for pitting edema __________________________________________
o Note deformities or enlarged joints ___________________________________
o Assess muscle bulk, tone, and strength _______________________________
o Sensation and reflexes ____________________________________________
o Observe abnormal movements ______________________________________
o With the patient standing:
o Varicose veins ___________________________________________________
o Alignment of spine ________________________________________________
o Range of motion _________________________________________________
o Alignment of the legs and feet ______________________________________
o Examine penis and scrotal contents __________________________________
o Check for hernias ________________________________________________
o Observe gait and ability to walk ______________________________________
o Romberg test and check for pronator drift. _____________________________

13. Nervous System

o Mental status. If indicated and not done during the interview, assess the patient’s
orientation, mood, thought process, thought content, abnormal perceptions, insight
and judgment, memory and attention, information and vocabulary, calculating
abilities, abstract thinking, and constructional ability
__________________________________________________________________
__________________________________________________________________
o Cranial nerves. If not already examined, sense of smell, strength of the temporal
and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength
of the trapezia and sternomastoid muscles
__________________________________________________________________
__________________________________________________________________
o Motor system. Muscle bulk, tone, and strength of major muscle groups. Cerebellar
function: rapid alternating movements (rams), point-to-point movements
__________________________________________________________________
__________________________________________________________________
o Sensory system. Pain, temperature, light touch, vibration, and discrimination
__________________________________________________________________
o Reflexes. Biceps, triceps, brachioradialis, patellar, achilles deep tendon reflexes,
plantar or babinski reflex ______________________________________________
__________________________________________________________________

14. Additional Examinations

o Men. Sacrococcygeal and perianal areas. Palpate anal canal, rectum, and prostate
__________________________________________________________________
o Women. Examine external genitalia, vagina, and cervix. Obtain a pap smear Palpate the
uterus and adnexa bimanually
__________________________________________________________________