HISTORY AND PHYSICAL EXAMINATION Pap Smear

Mammogram
Date of Interview: ______________________________ Occult blood in stool
Time of History: _______________________________ Cholesterol test
Informant: ____________________________________ Urinalysis
Relationship to the Patient: ______________________ Xray/CT Scan/MRI
% Reliability: _________ Others

General Data:
Patient’s Name: _____________________________ Menstrual and Obstetric History:
Age: ______ Sex: _______ Marital Status: ________ LMP: ____________ PMP: _______________
Address: _________________________________________________ Age of menarche: ____________ Period: regular/irregular
Birthday: ________________ Birthplace: _______________________ Character of flow: ____________
Nationality: ______________ Religion: _________________________ Duration of period (range): ____________
Occupation: __________________________ No. of pads used per day: ____________
PMS: ___________________________________________________
Date of Admission: ______________________ Age of Menopause: _______
Time of Admission: ______________________ Age of 1st coitus: ________ No. of sexual partners: __________
No. of times admitted at OM: ______________ History of post-coital bleeding, pelvic infection, dyspareunia?
Birth control methods used:
Chief Complaint: ________________________________________ Artificial Natural
 condom  rhythm method
History of Present Illness:  pills  withdrawal
Onset: _______________________________  spermicidal  abstinence
Duration: _____________________________ Others: ____________________________________
Frequency: ___________________________ Length of time used: _________
Setting at which the Symptom Occurred: _______________________ Complications: ______________________________
_______________________________________________________
Manifestations: ___________________________________________
Location: ________________________________________
Precipitating Factors: _______________________________ Gravidity: ______ Parity: _______
Quality: _________________________________________ OB Index: ________ Term
Radiation: _______________________________________ ________ Preterm
Severity: ________________________________________ ________ Abortions/Miscarriages
Aggravating Factors: ______________________________________ ________ Living Children
Alleviating Factors: ________________________________________ Date of Birth Sex Manner of Delivery
Previous Treatment for the Problem: __________________________ ______________________ ____________________
Associated Signs and Symptoms: _____________________________ ______________________ ____________________
________________________________________________________ ______________________ ____________________
Pertinent Positives and Negatives: ____________________________
________________________________________________________ OB Hx: G _ P_ (T-P-A-L)
Additional Notes: __________________________________________ G1: When _________, NSD or CS d/t _________, delivered by
________________________________________________________ _________, where _________, M/F, weight _________, fetomaternal
________________________________________________________ complications _____________________, present status __________.

Past Medical History: Family History:

Current Medications: Family Age Health/ Age & Date Cause of
Generic Brand Dosage Frequency Purpose Member Diseases of Dx death
Father
Mother
Others
Immunizations:
 BCG  DPT  Polio  Hepa B
Others: ________________________________________
Allergies: Medical Problems for any blood-relative
Food: ___________________________________
Relationship to Px Age & Date of Dx
Medications: ______________________________
Pollen/Animals/Others: ______________________ Cancer
Childhood Illness: Hypertension
 rheumatic fever  polio Diabetes
 chicken pox  measles Tuberculosis
 mumps Heart Disease
others: ______________________________ Stoke
Adult Illness: Kidney Disease
Illness Age Date of Diagnosis Arthritis
Hypertension Blood Disorder
Stroke Asthma
Renal Epilepsy
Asthma Mental Disorder
TB
DM
Cardiac Personal and Social History:
GI No. of years married: ______
STD Health Status of Spouse: ______________
Others No. of Children: _______
Health Status of Children: ___________________________________
Surgical Procedures: Highest Educational Attainment: ______________________________
Date: _______________________________ Occupational History: _______________________________________
Type of Operation: _____________________ ________________________________________________________
Purpose: _____________________________ ________________________________________________________
Previous Hospitalizations: Occupational Hazards: _____________________________________
Date Cause Hospital Treatment Smoking Habits:
 non-smoker  smoker ex-smoker
No. of sticks/packs per day: _________
Year started: ______ Year quitted: ______
Alcohol Consumption
 never  occasionally
Screening Tests:  daily  weekly
Test Date Result Alcohol type: ___________________
Tuberculin test Amount Consumed: ______________
Nutrition:  Discharge (characteristics): ________________
No. of meals per day: ________  Ulcers  Itching
Food preferences: ___________________ Peripheral vascular:
Coffee/tea/soda intake: _______________  Leg cramps  Varicose veins
Nutrient Supplement:: ________________ Muskuloskeletal:
OTC: _______________________  Muscle weakness  Stiffness
Prohibited Drugs: _____________  Backache  Joint swelling
Substance Abuse: _____________  Muscle pain  Join Pain
Exercise: ___________________________________ Neurologic:
Regularity of Sleep: ___________________________  Paralysis  Numbness
Habits/hobbies: ______________________________  Tremors  Seizures
Sources of Stress: ___________________________  Memory Loss
Coping Strategies: ___________________________ Hematologic:
Living Conditions:  Easy bruising  Bleeding
No. of years in current residence: _______  Pallor
Previous place of residence: ____________ Endocrine
___________________________________  Polydypsia  Polyphagia
Type of residence: ___________________  Heat/cold intolerance  Excessive sweating
No. of rooms: _______________________ Psychiatric:
No. of occupants: ____________________  Nervousness  Depression
Relationship to occupants: __________________________  Anxiety  Hallucinations
________________________________________________
Source of Drinking Water: ___________________________ PHYSICAL EXAMINATION
Garbage Disposal: _________________________________
Fecal Disposal: ___________________________________ General Survey:
Pet/s: __________________________________________ Mood: ______________
Personally gives bath to pets? Y/N Distress/ Unusual Position: _____________
General State of neighborhood: _____________________ Cooperative/ Non-cooperative
Irritable/agitated/pleasant
Review of Systems: Coherent: _________
Constitutional: Oriented to time and space: _______
 Fever  Weight gain/loss Personal Hygiene: _______________
 Chills  Fatigue Level of Consciousness: _______________
Skin: Height: ____________
 Rashes  Itching Weight: ____________
 Lumps  Dryness BMI: ______________
 Color Change  Changes in Nails
Hair: Vital Signs:
 Baldness  Excess Hair Temperature: ________  Oral  Axillary  Rectal
Head: Respiration: _________  Normal  Labored
 Headache  Dizziness Pulse: _____________  Regular  R. Irreg.  Irr. irreg.
 Lightheadedness  Trauma Blood Pressure: _______  Lying  Sitting  Standing
 Syncope  Tenderness
Eyes: Head:
 Pain  Redness Trauma: ________________________________
 Double Vision  Blurred Vision Size: ______________ Shape: _____________
 Use of Glass/Lenses  Photalgia Tenderness: __________________________________
 Lacrimation Condition of hair and scalp: _______________________________
Ears: Symmetry: ___________________________
 Hearing Problem  Earache Masses: _____________________________
 Discharge (color/consistency) ____________
 Tinnitus  Vertigo Eyes:
Nose and Sinuses: Visual acuity:
 Epistaxis  Nasal stuffiness Far: (R) ________ (L) ________
 Discharge (color/consistency): ____________ Near: (R) ________ (L) ________
 Itching Visual Fields (H test): ___________________
Mouth and Throat: Accommodation: _______________________
 Use of dentures  Mouth sores Test of confrontation: ___________________
 Bleeding Gums  Toothache Conjunctiva:
 Sore throat  Hoarseness Color: ____________________________
 Dysphagia Discharge: ________________________
Neck: Sclerae:
 Pain  Stiffness Color: ____________________________
 Lump Discharge: ________________________
Breast: Cornea:
 Pain  Discharge Clarity: ___________________________
 Lumps  Periodic Exam Corneal Arcus: _____________________
Lids: ______________ Iris: ________________
Respiratory: Position of eyes in orbits: ______________________________
 Cough  Sputum (color/quantity) ________ Pupil:
 Hemoptysis  Dysnea
 Wheezing Size: (R) __________ (L) ___________
Cardiovascular: Shape: ____________ Symmetry: ______________
 Chest Pain  Palpitations Accommodation: _______________
 Orthopnea  Edema Light reflex test (PERLA): ________________
 Cyanosis  Paroxysmal Nocturnal Dyspnea EOM: ________________________
 Easy Fatigability Visual Field: ____________________________
Gastrointestinal: Direct Reaction: ____________ Consensual Reaction: ____________
 Loss of appetite  Nausea Fundoscopic
 Vomiting  Hematemesis Red orange reflex: ______________
 Abdominal pain  Diarrhea Disc: ________________________
 Hematochezia  Excessive belching/passing of gas Macula: _____________________
Renal: Blood vessels: _________________
 Dysuria  Polyuria
 Nocturia  Gross Hematuria Ears:
 Incontinence  Urinary Retention Symmetry: _______________
 Urinary Urgency  Tea-Colored Urine  Swelling: ______________________________
In Males:  Redness: ______________________________
 Reduced caliber of force of stream  Discharge: ______________________________
 Hesitancy  Tenderness: _____________________________
 Dribbling  Hearing Impairments: _______________________
Genitalia:  Presence of Hearing Aid: _____________________
 Pain  Swelling Weber Test: ______________________________
Rinne Test: (R) AC __________ BC ___________ Tenderness: ______________ Mobility: _____________
(L) AC __________ BC ___________ Borders: _________________

Nose: Abdomen:
Symmetry: ___________________________ Inspection
Frontal, maxillary sinus tenderness: ____________________  Irregular Contours: ____________ Scars
Obstruction: __________________________  Discoloration: ________________
Congestion: __________________________  Bulges: _____________________
Lesions: _____________________________ Shape: _____________________
Exudates: ____________________________  Striae: ______________________
Inflammation: _________________________ Distance of umbilicus from xiphoid process: __________
Abdominal Girth: __________________
Throat: Auscultation
Lips: _____________________ Bowel Sounds: Frequency: ___________ Character: ____________
Teeth/dentures: _______________________  Bruit: ___________________
Gums: _______________________________  Venous Hum: ______________
Tongue: _____________________________  Friction Rub: _______________
Pharynx: Percussion
 Lesions: ______________  Erythema: _____________ Liver Span: _______________ Normal: 6-12 cm in (R)MCL
 Exudates: _____________ Tonsillar Size: _________ Splenic Dullness: ______________
Other Areas of Dullness: _______________
Neck: Special Tests
Symmetry: _________________________  Rebound Tenderness: Rovsing’s, Blumberg
Limitation of ROM: __________________  Costovertebral Tenderness
Tenderness: _________________________  Shifting Dullness
JVD: ______________________________  Psoas Sign
Lymph nodes: ________________________  Murphy’s Sign
Size: _____________
Mobility: ___________ Male Genitalia:
Tenderness: _____________  Penile Lesions: _______________
Borders: ________________  Scrotal Swelling: _______________________
Consistency: _____________ Testicles
Thyroid cartilage: _____________ Cricoid cartilage: ______________ Size: ________  Tenderness: ___________
Thyroid gland: ________________  Masses: ______________
 Varicocoele: _________________
Chest and Lungs  Hernia: ________________
Inspection Transillumination: ________________
Comfort and Breathing Pattern: _____________________
Shape of the Chest: ______________________________ Extremities:
Chest Movement: ________________________________ Amputation Visible joint swelling
 Use of Accessory Muscles of Breathing: ______________ Deformities Limitation of ROM
 Deformities of Asymmetry: _________________________ Tenderness Redness
 A/N Retraction of Interspaces on Inspiration: ___________ Warmth Edema
 Impairment of Respiratory Movement: ________________
Color of Patient (Lips & Nail Bed): ___________________ Capillary refill: ______________
Palpation Peripheral pulses: ___________
 Tender Areas: ___________________________________
Respiratory Expansion (10th rib): Symmetry  Yes  No
Tactile Fremitus: Symmetry  NEUROLOGICAL EXAMINATION
Increased Decreased Absent 
Percussion: ____________________________________ Mental Status Examination
Auscultation A. Awareness
Breath Sounds: _________________________________ Orientation
 Bronchophony  Whispered Petoriloquy Name:  Season  Date  Day  Month  Year
 Egophony Name:  Hospital  Floor  Town  State  Country
Level of consciousness:
Heart: B. Speech (Normal, dysphasia, dysarthria, dysphonia)
Inspection C. Language
Precordial bulge or heave: __________________ Name:  Pencil  Watch
PMI: __________________________ Repeat: “ No ifs  ands  or buts”
Palpation D. General Knowledge
PMI: __________________________ Knowledge of current events, vocabulary
Thrill: _____ (Historical events, 5 last presidents, 5 largest cities)
Location: _________________ E. Memory
Timing in Cardiac Cycle (S/D): ______________ Immediate, recent, remote
Mode of Extension/Transmission: ____________ F. Registration (Retention and recall)
 Friction Rub: ___________________ Identify:  Object 1  Object 2  Object 3
Percussion: Cardiac Borders Attention and Calculation
Right (cm) ICS/MSL Left (cm) (100-7…):  93  86  79  72  65
5th Recall
4th Recall:  Object 1  Object 2  Object 3
3rd G. Reasoning
- 2nd Judgment, Insight, abstraction (interpretation of proverbs)
H. Object recognition
Auscultation
Agnosia (Visual, tactile, auditory, autotopagnosia, anosognosia)
S1 (M-loud, T-split): ___________________
Praxis (Ideomotor, Ideational)
S2 (A,P-loud, P-split I): ___________________
Perception (Delusion, Hallucination, illusion, astereognosis,
S3: _________________________
agraphestesia)
Murmurs/Accessory Heart Sounds:
I. Follows Command
Location: __________________ Timing: _______________
 Take this paper.  Fold it in half.  Place it on the table.
Quality: ___________________ Pitch: ________________
 Obey written command.
Intensity: __________________ Radiation: _____________
 Write a sentence.
 Copy a design.
Breast:
Total: _____
Symmetry: _____________
 Dimpling/Skin Retraction: _____________________
Cranial Nerve Examination
 Swelling: ____________________
CN I
 Discoloration (Skin changes): _________________
 Identify odorant
 Orange Peel Effect: _________________
CN II
Position and Characteristic of Nipple: _________________
Visual acuity: ________ Visual field: _________
 Gynecomastia (Male): _________________
Fundoscopy: ____________________________________________
 Mass:
CN III, IV, VI
Location: _____________________________
Size and Shape of Pupil: __________________
Size: ___________ Consistency: _________________
 Light Reaction  Accommodation  Ankle
EOM: Superficial
 Paresis  Nystagmus  Abdominal
 Saccades  Oculomotor Ataxia  Cremasteric
 Diplopia  Other _____________ Reflexes in Infants
CN V  Grasp
 Ophthalmic  Maxillary  Suck
 Mandibular  Corneal Reflex  Moro
 Jaw Clench  Rooting
CN VII  Tonic neck
 Eyebrow Elevation  Forehead Wrinkling  Babinski
 Eye Closure  Smiling
 Cheek Puffing Sensory
CN VIII  Pin prick
 Hear finger rub or whispered voice  Touch
Rinne: ____________ Weber: ____________ Two point discrimination
CN IX, X  Sense of Position
Palate and Uvula: _____________  Vibratory Sense
 Gag Reflex  Superficial sensation
CN XI  Deep Sensation
 Shoulder Shrug (against resistance)
 Head Rotation (against resistance)
CN XII (Tongue)
 Atrophy  Fasciculation
Position with protrusion: _________
Strength: __________

Motor Examination
 Involuntary Movements
 Symmetry
 Atrophy
 Gait
 Paresis
 Paralysis
 Spasticity
 Rigidity
 Flaccidity
 Clonus
 Carpopedal Spasm
 Tics
 Tremors
 Athetosis
 Others

Tone
Description: ____________________________
 Flaccidity
 Spasticity

Muscle Strength

(R) (L)
Shoulder Flexion
Extension
Abduction
Adduction
IR/ER
Flexion at the elbow
Extension at the elbow
Extension at the wrist
Squeeze 2 of your fingers as hard as possible
Finger abduction
Opposition of the thumb
Flexion at the hips
Adduction at the hips
Abduction at the hips
Extension at the hips
IR/ER
Extension at the knee
Flexion at the knee
Dorsiflexion at the ankle
Plantar flexion

Coordination and Gait

 Rapid Alternating Movements
 Point to Point Movements
 Romberg
Gait
 Walk across the room, turn and come back
 Walk heel-to-toe in a straight line
 Walk on heels in a straight line
 Walk on toes in a straight line
 Hop in place on each foot
 Shallow knee bend
 Rise from a sitting position

Reflexes
Deep Tendon
 Biceps
 Triceps
 Brachioradialis
 Knee