Far Eastern University History and Physical Examination

Nicanor Reyes Medical Foundation

Department of Internal Medicine Proctor’s Signature:

Name of Interviewer: Informant:

CD - Section Date of Interview: Reliability:

I. General Data
Completeness
(Name of Patient) (Age) (Sex) (Civil Status) (Nationality) (0) N/A (1) <9 data
(2) >9 data (3) Complete

(Religion) (Occupation) (Birthdate) (Birthplace) Recorded in a telegraphed

manner
(0) N/A (1) No (2) Yes
(Present Address)

(No. of times admitted) (Date Admitted)

II. Chief Complaint Briefly written using phrases,

and not sentences
(0) N/A (4) No (8) Yes

III. History of Present Illness

Recorded time of onset

properly
(0) N/A (3) No (6) Yes

Observed chronology of
symptoms
(0) N/A (4) No (8) Yes

Described symptoms
adequately
(2) <25% (5) 25-50%
(7) 50-75% (10) >75%

Included all pertinent positive

and negative information
regarding the system that may
be associated with each
symptom
(2) <25% (5) 25-50%
(7) 50-75% (10) >75%

Noted consultation done

(0) N/A
(2) Recorded, but inadequate
(4) Recorded data is adequate

Noted medications given

(0) N/A
(2) Recorded, but inadequate
(4) Recorded data is adequate

THE WRITTEN HISTORY IS:

Neat
(1) <50% (2) 50% (3) >50%

Legible
(1) <50% (2) 50% (3) >50%

Properly paragraphed
(1) <50% (2) 50% (3) >50%

Grammatically correct
(2) <50% (3) 50% (5) >50%

With minimal use of

universally accepted
abbreviations
(1) <50% (2) 50% (3) >50%

Brief and concise

(2) <50% (3) 50% (5) >50%
I. Past Medical History [[ ifClick
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Childhood Diseases: ( ) Childhood diseases /
Immunizations: ( ) Immunizations / Adult
Adult Diseases: Diseases / Psychiatric Illnesses
Hypertension: ( ) (0) (1) (3)
Diabetes: ( )
Bronchial Asthma: ( )
COPD: ( )
Pulmonary Tuberculosis: ( )
Myocardial Infarction: ( )
Cerebrovascular Accident: ( )
Malignancy: ( )
Allergies: ( )
Psychiatric Illnesses: ( )
Previous Surgery: ( ) Surgical diseases / Gynecologic
Gynecologic Diseases: ( ) Diseases / Accidents and
Injuries / History of blood
Accidents / Injuries: ( )
transfusion
Blood Transfusion: ( )
(0) (2) (4)
Others (please specify):

II. Family History Family History

Father: (0) (1) (3)
Mother:
Siblings:
Others:

III. Personal and Social History Personal and Social History

Education: Marital Status: (0) (3) (5)
Occupation: Lives with:
Living Condition: Food Preference:
Leisure Activities: Exercise Regimen:
Sexual Practices: Smoking History:
Alcohol Intake: Use of Illicit Drugs:
Others (if applicable):

IV. Obstetric and Menstrual History Obstetric / Menstrual History

Menarche: Interval: Duration: Amount: (0) (1) (3)
Symptoms: G: P: (T: P: A: L: )
Manner of Delivery: Complications:

V. Review of Systems [[ ifClick

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Constitutional: ( ) weight loss (0) (3) (5)
Skin: ( ) itchiness, ( ) change in color, ( ) dryness
Head: ( ) vertigo, ( ) dizziness
Eyes: ( ) pain, ( ) blurring of vision, ( ) double vision,
( ) excessive lacrimation, ( ) photophobia, ( ) use of eyeglasses
Ears: ( ) earache, ( ) deafness, ( ) tinnitus, ( ) ear discharge
Nose / Sinuses: ( ) change in smell, ( ) nose bleeding, ( ) nasal obstruction, TOTAL SCORE: ___________
( ) nasal discharge, ( ) pain over paranasal sinuses REMARKS:
Mouth / Throat: ( ) toothache, ( ) gum bleeding, ( ) disturbance in taste,
( ) sore throat, ( ) hoarseness
Neck: ( ) pain, ( ) limitation of movement, ( ) presence of mass
Respiratory: ( ) shortness of breath, ( ) difficulty of breathing
Cardiovascular: ( ) substernal pain, ( ) orthopnea, ( ) syncope,
( ) paroxysmal nocturnal dyspnea
Gastrointestinal: ( ) dysphagia, ( ) melena, ( ) hematochezia, ( ) regurgitation
Genitourinary: ( ) anuria, ( ) incontinence, ( ) dysuria, ( ) urinary frequency,
( ) urethral discharge
Extremities: ( ) stiffness, ( ) intermittent claudication,
( ) limitation of movements
Nervous ( ) syncope, ( ) loss of consciousness, ( ) focal weakness,
System: ( ) paralysis, ( ) numbness, ( ) paresthesia, ( ) speech disorder,
( ) loss of memory, ( ) confusion
Hematopoietic: ( ) bleeding tendency, ( ) easy bruising, ( ) pallor
Endocrine: ( ) intolerance to heat and cold, ( ) polyuria, ( ) polydipsia
 VI. Physical Examination

Point System:
Details of Physical Examination (N/A) (Recorded, but inadequate) (Recorded, adequate)

General Survey:

GENERAL APPEARANCE
General Appearance General Survey (0) (2.5) (5)
Vital Signs:
Vital Signs (0) (2.5) (5)

SKIN, HEAD, EYES, EARS, NOSE, THROAT

Skin (0) (1) (2)
Head and Face (0) (1.5) (3)
Skin Eyes (0) (3) (6)
Ears (0) (1) (2)
Nose / Sinuses (0) (1) (2)
Oral Cavity (0) (2.5) (5)

EXAMINATION OF THE NECK

Trachea, Thyroid, Lymph Nodes
(0) (2) (4)
Head, Eyes, Ears, Nose,
Throat

EXAMINATION OF THE CHEST / LUNGS

Inspection (0) (2) (4)
Palpation (0) (1.5) (3)
Percussion (0) (0.5) (1)
Auscultation (0) (1.5) (3)

EXAMINATION OF THE HEART

Neck
Precordium/Apex beat
(0) (2) (4)

Inspection: Carotid Evaluation (0) (0.5) (1.5)

JVP Evaluation (0) (0.5) (1.5)
Palpation:
S1, S2, Cardiac Rate, Rhythm, Heart Sounds
Chest / Lungs
Percussion: (0) (1.5) (3)
Auscultation:

Inspection: EXAMINATION OF THE ABDOMEN

Inspection (0) (1.5) (3)
Palpation:
Auscultation (0) (1) (2)
Heart
Percussion: Percussion (0) (2) (4)
Palpation (0) (3) (6)
Auscultation:

Inspection:
EXAMINATION OF THE EXTREMITIES / SPINE
Auscultation:
Spine (0) (1) (2)
Abdomen
Percussion: Upper Extremities (0) (2) (4)
Lower Extremities (0) (2) (4)
Palpation:

NEUROLOGIC EXAMINATION
Cerebrum (0) (2) (4)
Extremities / Spine
(Level of Consciousness, General Behavior, Appearance,
Orientation, Memory)

Cerebellum (0) (1) (2)

Cranial Nerves (0) (2) (4)
5 5 Motor Function (0) (1.5) (3)
Sensory Function (0) (1) (2)
Reflexes (0) (1.5) (3)
(Superficial Reflexes, DTR’s, and Pathologic Reflexes)
5 5
MOTOR Gait/Meningeal Signs (0) (1) (2)

100% 100%
Neurologic / Mental
TOTAL SCORE: ___________
Status
REMARKS:
100% 100%
SENSORY

+2 +2

+2 +2
REFLEXES AJRU