ADULT HISTORY

DATE: ______________ TIME: ____________ ( ) BCG =

SOURCE OF HISTORY: _______ RELIABILITY: __________ _____________________________________________
( ) OPV =____________________________________________
GENERAL DATA: ( ) DPT =
NAME: _________________ ____________________________________________
AGE: ________ y.o. ( ) HEP
SEX: ________ =______________________________________________
MARITAL STATUS: ____________________ ( ) MMR
RELIGION: ___________________________ =_____________________________________________
NATIONALITY: ________________________ ( ) PNEUMOCOCCAL =
OCCUPATION: _______________________________________ ________________________________
ADDRESS: __________________________________________ ADULT ILLNESSES:
DATE OF BIRTH: _____________________________________ ALLERGIES:
PLACE OF BIRTH: ____________________________________ ( ) Food =
DATE OF ADMISSION: ________________________________ _____________________________________________ ( )
NUMBER OF ADMISSION: _____________________________ Medications = ________________________________________
PLACE OF ADMISSION: ________________________________
MEDICAL: ( ) DM = ______( ) HPN = _____ ( ) Hepa
CHIEF COMPLAINT: __________________________________ =______
( ) Asthma = ______ ( ) Arthritis = _______
HISTORY OF PRESENT ILLNESS: Medications:
ONSET: DURATION: NATURE & CHARACTER: ________________________________________
SEVERITY: Hospitalization: (where, when, why, md, dx, tx)
AGGRAVATING CONDITION: RELIEVING CONDITION:
ASSOCIATED SYMPTOMS:
( ) fever ( ) body malaise
( ) flu
( ) cough ( ) headache ( )
abdominal pain
EFFECTS ON: FEEDING, SLEEP, ACTIVITY, Physiology SURGICAL/ ACCIDENTS & INJURIES
(urination, defecation)
MEDICATIONS: (name, dosage, frequency, response)
PERTINENT: NEGATIVE: POSITIVE

OB – GYNE:
Menstrual Hx:
Menarch
Amount
Duration
Interval
Regularity

Birth Control: & reason why stopped?

Sex Partners:
thru out life?
Last 3-6 months?
Last yr?
G___ P___ (T___ P___ A___ L___)
PSYCHIATRIC:

SCREENING TEST: (when, result)

( ) xray: ___________________ ( ) FBS:
____________________
( ) U/A: _________________ ( ) CBC:
____________________
( ) Pap smear: __________________________________
PAST MEDICAL HISTORY: Others:
CHILDHOOD ILLNESSES: _______________________________________________
( ) ASTHMA = ___________ ( ) MUMPS =
___________ PERSONAL / SOCIAL HISTORY:
( ) CHICKEN POX= ________ ( ) MEASLES = OCCUPATION: _________________________________________
_________ EDUCATION: __________________________________________
IMMUNIZATION HISTORY: (when? Where?, # of RELIGION: _____________________________________________
dose) HOBBIES: _____________________________________________
SMOKING: _____________________________________________
ALCOHOL INTAKE: _____________________________________ ( ) cooperative ( ) calm ( )
SLEEP PATTERNS: _____________________________________ hostile
EXERCISE: ____________________________________________ ( ) uncooperative ( ) depressed ( )
SPOUSE: ____ yo = HEALTH: apathetic
______________________________ ( ) nervous ( ) tense ( )
CHILD 1: ____ yo = HEALTH: angry
_____________________________ 3. GAIT:
CHILD 2: ____ yo = HEALTH: ( ) ambulatory ( ) nonambulatory ( )
_____________________________ hemiplegic
CHILD 3: ____ yo = HEALTH: ( ) steppage ( ) tabetic ( )
_____________________________ scissors
CHILD 4: ____ yo = HEALTH: ( ) Parkinsonian
_____________________________ 4. POSTURE:
HOME SITUATION: ( ) normal erect ( ) stooped ( )
Where: ( ) city ( ) province; lordosis
___________________________________________________ ( ) kyphosis ( ) scoliosis ( )
_ ophisthotonus
Type: ( ) owned ( ) rented ( ) decorticate rigidity ( ) decerebrate rigidity
___________________________________________________ 5. HEIGHT: ( ) tall ( ) short
_ 6. BUILD: ( ) slender ( ) lanky ( ) muscular ( )
Living with?
stocky
________________________________________________
Proportions: ___________________________
Source of water:: ( ) MCWD ( ) distilled ( )
purified 7. WEIGHT: ( ) emaciated ( ) slender
( ) deep well ( ) mineral ( ) ( ) plump ( ) obese
boiled 8. STATE OF NUTRITION:
BMI:
FAMILY MEDICAL HISTORY: ( ) underweight ( ) normal ( ) overweight ( )
MA GRANDPA: ____ yo = HEALTH: obese
_______________________ 9. DRESS, GROOMING, & PERSONAL HYGIENE:
MA GRANDMA: ____ yo = HEALTH: ( ) jewelry ( ) tattoes ( ) piercing
______________________ ( ) nail polish/ hair color =
PA GRANDPA: _____yo = HEALTH: ________________________
________________________ ( ) clothes =
PA GRANDMA: ____ yo = HEALTH: ____________________________________
_______________________ 10. FACIAL EXPRESSION:
MOM: ____ yo = HEALTH: ( ) natural ( ) sustained &
________________________________ unblinking
DAD: _____ yo = HEALTH: ( ) avert quickly ( ) absent
_______________________________ 11. ODORS (BODY/ BREATH)
SIB 1: ____ yo = HEALTH: _____________________________________________
_________________________________ 12. MOTOR ACTIVITY:
SIB 2: ____ yo = HEALTH: ( ) no abnormal movements ( ) chonca
________________________________
SIB 3: ____ yo = HEALTH: ( ) tics ( ) athetosis ( ) dystonia ( )
_________________________________ tremors
SIB 4: ____ yo = HEALTH:
_________________________________ VITAL SIGNS
HEREDOFAMILIAL DISEASE: 1. HEIGHT/ LENGHT = ______________ cm
( ) DM ( ) HPN ( ) HEART 2. WEIGHT = _________________ lbs / Kg
DISEASE 3. TEMPERATURE = _______OC, ___________,
( ) ASTHMA ( ) ANEMIA ( ) KIDNEY DISEASE ________
( ) CANCER ( ) ALLERGIES ( ) LUPUS 4. BLOOD PRESSURE = _____/______,
( ) RHEUMATOID ARTHRITIS ________,_______
5. RESPI RATE = ________breaths/ min ______,
PHYSICAL EXAMINATION: ________
GENERAL SURVEY: 6. HEART RATE = _______beats/ min, _______,
1. LEVEL OF CONSCIOUSNESS: ________
( ) alert ( ) awake ( ) oriented
( ) confused
7. PULSE RATE = _______ beats/ min, _______,
________
( ) delirious ( ) lethargic ( ) stuporous ( )
obtundation
SKIN:
( ) coma ( ) deep coma / light coma)
1. COLOR
( ) unconscious
( ) brown ( ) fairly - white
2. MENTAL STATUS AND MOOD:
( ) loss of pigmentation( ) white
( ) oriented ( ) coherent ( ) incoherent
( ) redness ( ) black
( ) pallor ( ) cyanotic
( ) yellow
 2. MOISTURE 3. POSITION & ALIGNMENT OF EYES:
( ) dry ( ) sweaty ( ) oily ( ) moist ______________
3. TEMPERATURE 4. EYEBROWS:
( ) warm ( ) cool ____________________________________
4. TEXTURE 5. ORBITAL RIM:
( ) rough ( ) smooth __________________________________
5. MOBILITY (ease to lift skin) AND TURGOR 6. EYELIDS:_______________________________________
(speed of return)
7. EYELASHES: __________________________________
Mobility =
8. PALPEBRAL FISSURE:
_______________________________________
___________________________
Turgor = ( ) good turgor ( ) bad turgor
9. LID CLOSURE:
6. LESIONS ( ) present ( ) absent __________________________________
Types: ( ) flat (macule, patch) 10. CORNEA LIGHT REFLEX:________________________
( ) elevated superficial (papule, 11. BULBAR CONJUNCTIVA:
plaque)
_________________________
( ) elevated deep ( nodule, tumor)
( ) elevated cystic (vesicle, bulla, 12. SCLERA:
pustule) _______________________________________
( ) depressed (atrophy, erosion, ulcer, 13. LOWER PALPEBRAL CONJUNCTIVA:
fissure) _______________________________________________
( ) scar ( ) nevi 14. UPPER PALPEBRAL CONJUNCTIVA:
( ) secondary lesion ( crust, _______________________________________________
lichenification, scars, keloids, erosion, 15. CORNEA: __________________________________
excoriation, fissure, ulcer) 16. LENS:
Color: __________________________________________
__________________________________________ 17. PUPILS:
Anatomic location/ position: ________________________________________
_______________________________________________ Direct: ___________________
________________- Consensual: ___________________
________________________________ 18. EXTRAOCULAR MOVEMENTS:
Patterns: ( ) scattered ( ) generalized
( ) confluent
( ) anular ( ) arciform ( )
serpiginous
( ) clustered ( ) linear ( ) 19. TONOMETRY:
geographical OS:_____________________________
( ) combination OD:____________________________
Size: __________________________________________ 20. FUNDUSCOPY:
Shapes: ______________________________________ OS OD
Distribution: ROR: ___________ ____________
____________________________________ CM: ___________ ____________
DDB: ___________ ____________
HAIR: CD: ___________ ____________
1. COLOR: AV: ___________ ____________
________________________________________ hge: ___________ ____________
AMOUNT: exudate: ___________
______________________________________ ____________
2. DISTRIBUTION: ________________________________ FR: ___________ ____________
3. THICKNESS:
____________________________________ EARS:
4. TEXTURE: _____________________________________ 1. AURICLES:
5. PRESENCE OF PARASITE:_______________________ _____________________________________
2. CANALS: ______________________________________
NAILS: 3. DRUMS:
1. COLOR: ______________________________________ ________________________________________
2. SHAPE: ________________________________________ 4. AUDITORY ACUITY: _________________________
3. ABNORMALITY: ( ) no clubbing ( ) no cyanosis
4. LESIONS: ______________________________________ NOSE:
1. EXTERNAL NOSE:
EYES: ______________________________
1. VISUAL ACUITY: OS:_________ w/ 2. NASAL MUCOSA:
pinhole: ______ _______________________________
OD: ________ w/ pinhole: 3. SEPTUM:
______ _______________________________________
2. VISUAL FIELDS:
________________________________
4. TURBINATES: __________________________________
 5. SINUSES (FRONTAL & MAXILLARY): CN XI I –
_______________________________________________

THROAT: MOTOR
1. LIPS: _________________________________________ left right
2. ORAL MUCOSA: Muscl
_________________________________ e
stren
3. GUMS: ______________________________________ gth
4. TEETH: ________________________________________ UE
5. TONGUE: ______________________________________ LE
6. TONSILS: _____________________________________ Muscl
7. PHARYNX: _____________________________________ e
tone
NECK: UE
1. CERVICAL LYMPH NODES: LE
_______________________________________________
_ SENSORY
2. MASSES: ______________________________________ left right
3. TRACHEA: _____________________________________ UE
4. THYROID GLAND: LE
______________________________
CARDIOVASCULAR SYSTEM
HEAD Neck
Inspection: Inspection:

Palpation: Palpation: carotid pulse?

FACE Extremities
Inspection: UE LE
Inspecti
Palpation: on
Palpatio
n
MENTAL STATUS Chest
Inspection: gross deformities?

Palpation: PMI?

Percussion: Cardiac borders?

CRANIAL NERVES Auscultation: Heart sounds? Normal? Abnormal?

CN I –

CN II – MUSCUSKELETAL SYSTEM
UE LE
CN II & II- pupillary lighr reflex ROM
Active
CN III, IV & VI – EOM
Passive
CN V –
V1 Pain
V2
V3 Guarding

CN V & VII- corneal reflex Deformities

CN VII - CHEST AND LUNGS

Ant Chest
CN VIII - Inspection: deformities? Lag?

CN IX – Palpation: symmetry of expansion? Tactile fremitus?

CN X – Percussion:

CN XI – Auscultation: breath sounds? Adventitious breath

sounds?
Post Chest
Inspection: Lag?

Palpation: symmetry of expansion? Tactile fremitus?

Percussion:

Auscultation: breath sounds? Adventitious breath

sounds?

ABDOMEN
Inspection: contour? Striae?

Auscultation: bowel sounds? Bruits? Venous hum?

Palpation: LIVER: Peristalsis? Tender appendix?

Kidneys?

Percussion: liver span? Spleen?

LOGICAL IMPRESSION:

DIFFERENTIAL DIAGNOSIS:
1.

2.

3.