history and pe sheet excel

8/20/2019 History and Pe Sheet Excel

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ROTATION

DATE AND TIME

PLACE OF INTERVIEW

I. GENERAL INFORMATION

NAME

MARITAL STATUS

DATE OF ADMISSIONADDRESS

SOURCE OF INFORMATION

II. CHIEF COMPLAINT

P Precipatating?

Q Qualit?

R Relie!?

S Acc"#paning $#pt"#$?

T Ti#ing?

III. HISTORY OF PRESENT ILLNESS

DAYS/WEEKS PTA COMPLAINTS

IV. PAST MEDICAL HISTORY

C%ILD%OOD ILLNESSES

IMMUNI&ATIONS

ADULTILLNESSES

MEDICATIONS 'DRU() DOSA(E) PURPOSE*

ALLER(IES

SRU(ERIES

V. PERSONAL AND SOCIAL HISTORY

SMO+ER? Age $tarte,? Pac- ear$?

ALCO%OLIC DRIN+ER? Age $tarte,? %". "!ten? N"/ 0"ttle$ per ,a? +in, "! alc"1"l?

ILLICIT DRU( USE Age $tarte,? W1at -in, "! ,rug? %". "!ten?OCCUPATION

EDUCATIONAL ATTAINMENT

%OUSE ENVIRONMENT li2ing .it1? %". #an r""#$? Ventilati"n?

WATER SOURCE

(RA3A(E COLLECTION

FOOD SOURCE

DIET tpical #eal? !a2"rite !"",?

%A3ITS c"!!ee?

VI. FAMILY HISTORY


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FAMIL4 MEM3ER CAD

VII. OBSTETRIC AND GYNECOLOGICAL HISTORYO3 SCORE G P ( F P A L )

PRE(NANC4 4EAR

MENARC%

MENSTRUATION Regular? N"/ ,a$ per #"nt1l ccle? N"/ 0lee,ing ,a$? N"/ pa,$5,a) pre

SE6UAL %ISTOR4 %a, STD 0e!"re? Se7 .it1 ,"#e$tic $e7 ."r-er$?

A(E FIRST SE6

CONTRACEPTION Met1",? %". #an ear$? Rea$"n !"r c1anging5$t"pping?

NO/ OF SE6UAL PARTNERS At pre$ent? Entire li!e?

VIII. REVIEW OF SYSTEMS

(ENERAL

Weig1t L"$$5(ain Napan$ing pag0a0ag" $a ti#0ang

Fatigue palaging pag",

Fe2er lagnat

C1ill$

Tr"u0le Sleeping 1irap $a pagtul"g

S+IN

Ra$1e$

Lu#p$

Itc1ing

Drne$$

C"l"r C1ange$

%air an, nail c1ange$

%EENT

%ea,ac1e

%ea, In8ur

Nec- Pain

Decrea$e, 1earing

Ear Di$c1arge

Ringing in ear$

Earac1e

Vi$i"n L"$$5C1ange$

Ee pain

Ee re,ne$$

3lurr5,"u0le 2i$i"n

Fla$1ing lig1t$

Spec-$

N"$e Stu!!ine$$


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N"$e Di$c1arge

N"$e0lee,$

Sinu$ pain

Denture$

S"re t"ngue

S"re t1r"at

Dr #"ut1

%"ar$ene$$

T1ru$1

N"n91ealing $"re$

Nec- Lu#p$

S."llen glan,$

Nec- pain

Nec- $ti!!ne$$

IX. PHYSICAL EXAMINATION

A/ (ENERAL SURVE4

APPARENT STATE OF %EALT%

LEVEL OF CONSCIOUSNESS

SI(NS OF DISTRESS

3UILT) 3OD4 S4MMETR4 AND POSTURE

%EI(%T

3MI

3/ VITAL SI(NS

3P

%R

C/ %EENT

%EAD

E4ES VISUAL ACUIT4

VISUAL FIELD 'CONFRONTATION*

POSITION ALI(NMENT OF E4ESE4E3ROWS

E4ELIDS

LACRIMAL APPARATUS

CON:UNCTIVA ; SCLERA

CORNEA ; LENS

IRIS

PUPILS

E6TRAOCULAR MUSCLES

OP%T%ALMOSCOPIC E6AM

EARS AURICLE

EAR CANAL AND DRUM


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AUDITOR4 ACUIT4

AIR AND 3ONE CONDUCTION

LATERALI&ATION

NOSE AND PARANASAL SINUSES I< Anteri"r an, In!eri"r $ur!ace$ "! t1e n"$e

Te$t !"r Na$al "0$tructi"n

I< in$i,e "! n"$e

NASAL SEPTUM

A0n"r#alitie$< ulcer$ an, p"lp$

Sinu$ Ten,erne$$

MOUT% AND P%AR4N6 LIPS

ORAL MUCOSA

(UMS AND TEET%

ROOF OF MOUT%

TON(UE AND FLOOR OF MOUT%

P%AR4N6


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A(E

(ENDER

RELI(IONDATE OF 3IRT%

RELIA3ILIT4

CHARACTER


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%TN AST%MA

LMP

A(E MANNER OF DELIVER4

MENOPAUSE

ence "! $#pt"#$?

3REAST

Lu#p$

Pain

Di$c1arge

Di#pling

C1ange in c"l"r

RESPIRATOR4

C"ug1

Sputu#

C"ug1ing up 0l"",

S1"rtne$$ "! 3reat1

W1ee=ing

Pain!ul 0reat1ing

CARDIOVASCULAR

C1e$t pain5,i$c"#!"rt

C1e$t tig1tne$$

Palpitati"n$

Di!!icult "! 0reat1ing

S.elling

PND

SO3 .it1 acti2it

DO3 .1ile ling ,".n

(ASTROINTESTINAL

S.all".ing ,i!icultie$

%eart0urn

C1ang in appetite

Nau$ea

C1ange in 3".el


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Rectal 3lee,ing

Ca"n$tipati"n

Diarr1ea

4ell". ee$ "r $-in

URINAR4

Fre>uenc

Urgenc

3urnng5pain

3l"", in urine

Inc"ntinence

C1ange in urinar $trengt1

VASCULAR

Cal! pain .it1 .al-ing

Leg Cra#ping

NORMAL

WIE(%T

RR

TEMPERATURE

I< $1ape an, $##etr

Pupillar Reacti"n T" Lig1t

I< re!lecti"n$ in c"rnea$

C"2er9Unc"2er Te$t

E7tra"cular #"2e#ent$ C"n8ugate #"2e#ent$) ,e2iati"

C"n2ergenceI< Optic Di$c $1arpne$$ "r clarit "! ,i$c "utli

c"l"r "! ,i$c

$i=e "! central p1$i"l"gic cap

pre$ence "! 2en"u$ pul$ati"n$

c"#parati2e $##etr "! ee$

I< Retina arterie$) 2ein$) AV cr"$$ing$) !"

le$i"n$

I< De!"r#itie$) lu#p$ an, $-in le$i"n$

TU( TEST

I< Ear canal) ear,ru#) 1an,le "! #alleu$) $1"rt an, l"ng pr"ce$$ "! #alleu$


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R%INNES TEST

WE3ER TEST

A$$#etr) ,e!"r#it

Na$al #uc"$a< $.elling) 0lee,ing an, e7u,ate

,e2iati"n) in!la##ati"n) p"r!"rati"n

c"l"r) #"i$ture) lu#p$) ulcer$) crac-ing "r $caline$$

c"l"r) ulcer$) .1ite patc1e$ an, n",ule$

c"l"r "! gu#$

teet1< an #i$$ing) ,i$c"l"re,) #i$1appen "r a0n"r#all p"$iti"ne,

c"l"ra@ ; arc1itec1ture "! 1ar, palate

$##etr "! t"ngue

I< c"l"r an, te7ture "! ,"r$u# an, un,er$i,e$ "! t"ngue

I< $"!t palate) anteri"r an, p"$teri"r pillar$) u2ula) t"n$il$ an, p1arn7

c"l"r an, $##etr

e7u,ate) $.elling ulcerati"n ; t"n$ilar enlarge#ent


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CANCER DM LIVER D6 OT%ERS NOTES

PLACE OUTCOME COMPLICATIONS5NOTES

MUSCULOS+ELETAL

Mu$cle Pain

:"int Pain

Sti!!ne$$

3ac- Pain

Re,ne$$ "! :"int$

S.elling "! :"int$

Trau#a

NEUROLO(IC

Di==ine$$

Fainting

Sei=ure$

Wea-ne$$

Nu#0ne$$

Tingling

Tre#"r

%EMATOLO(IC

Ea$e "! 0rui$ing

Ea$e "! 0lee,ing

ENDOCRINE

%eat "r c"l, int"lerance

S.eating

Fre>uent urinati"n

T1ir$t

C1ange in appetite

PS4C%IATRIC

Ner2"u$ne$$

Stre$$


11/12

Depre$$i"n

Me#"r L"$$

n$) n$tag#u$) li, lag

ne

ae an, #acula


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history and pe sheet excel

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