medical health examination form

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KLPR MEDICAL HEALTH EXAMINATION FORM Date: ________ Time: _____

Name: ________________________________ Age: ___ Gender: ___ Civil Status: ________ Nationality: __________ Religion:_____________ Occupation: _______________ Place of Birth: ______________ Date of Birth: __________ Current Address: _____________________________ # of admission/consultation: ___ Date/Time of adm.: __________ Informant: _____________________ %Reliability: ___ Preceptor: ______________ Date of Submission: __________

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

Childhood Illnesses: ______________________________

________________________________________________

Childhood Immunizations: __________________________

________________________________________________

Adult Illnesses: __________________________________

________________________________________________

________________________________________________

Adult Immunizations: ______________________________

________________________________________________

Previous Hospitalizations/Surgeries: None Yes

________________________________________________

________________________________________________

________________________________________________

Allergies: _______________________________________

Blood Transfusion/s: None Yes: _________________

________________________________________________

________________________________________________

Medications: ____________________________________

________________________________________________

________________________________________________

FAMILY HEALTH HISTORY

Age, Health Status, Deceased (Cause), etc

Father: __________________________________________

Mother: _________________________________________

Siblings: ________________________________________

________________________________________________

Relatives: _______________________________________

Indicate Family member and specify conditions/diseases:

Hypertension: ___________________________________

Diabetes Mellitus: _______________________________

Cerebrovascular Accident: ________________________

Obesity: _______________________________________

Tuberculosis (specify): ___________________________ Malignancies (specify): __________________________

Heart Problems (specify): _________________________

Coronary Artery Disease: _________________________

Congestive Heart Failure: _________________________

Rheumatic Heart Disease: _________________________

Thyroid Disorders (specify): ______________________

Liver Cirrhosis: _________________________________

Renal Failure: __________________________________

Gout: _________________________________________

Asthma: _______________________________________

Seizure Disorder: _______________________________

Chromosomal abnormality: _______________________

Hematologic Disorder: ___________________________

Congenital Defect: ______________________________

Psychiatric Disorder: ____________________________

Sudden Death: _________________________________ Others: ___________________________________________

Remarks: _______________________________________

PERSONAL and SOCIAL HISTORY

Educ. Attainment and Economic Background: _______

________________________________________________

Work Experience/Condition/Hazards: _______________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

Cigarette Use: No Yes, Pack Years: ______________

Sticks per Day: ________ Since When?: ____________

Second-hand Smoke: No Yes, ___________________

Alcohol Use: No Yes, type of beverage: ___________ Frequency: _________ Since When?: ______________

Substance Abuse: , specify: ________________

________________________________________________

Use of Stimulants: ________________________________

________________________________________________

Interests/Lifestyle/Exercise: ________________________

________________________________________________

________________________________________________

________________________________________________

Sleep Pattern/Naps: _______________________________

________________________________________________

Food Preferences: ________________________________

________________________________________________

Housing Conditions: Type of House: _________________

Size: _________________ # of residents: _____________

# of Windows: __________ # of bedrooms: ____________

Source of Ventilation: ______________________________

Home Environment: ______________________________

________________________________________________

Home Vectors: ___________________________________

Water Supply: ___________________________________

Toilet and Sewage: _______________________________

Garbage Disposal: ________________________________

Others: _________________________________________

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OB- GYNE HISTORY

MENSTRUAL HISTORY:

Menarche Age: _____ (flow): _______________________

________________________________________________

Menstrual Cycle:

Menopause

Interval: _______________ Duration: ______________

Amount: _______________________________________

Amenorrhea Dysmenorrhea Menorrhagia Menopause Galactorrhea

Remarks: ________________________________________

OBSTETRICAL HISTORY: LMP: __________________

OB SCORE: Gravida: ____ Parity:_____ Term: _____

Preterm: ____ Abortion: ____ Living: ____ G1 G2 G3 G4 G5 G6 G7

Sex

Date of

Delivery

Full-term/

Pre-term

Type of

Delivery

Person-

in-charge

Place of

Delivery

Condition

at Birth

Use of Contraceptives: No Yes, specify: ____________

_______________________________________________

OB Surgeries: ____________________________________

GYNECOLOGIC HISTORY: ______________________

________________________________________________ Remarks : _______________________________________

REVIEW OF SYSTEMS

General

fever chills malaise fatigability weight change

Remarks: ______________________________________

Integumentary pruritus pigmentation/texture change lesions/sores

Remarks: ______________________________________

Head and Neck headache dizziness syncope blurring of vision

diplopia photophobia eye pain hearing loss

ear discharge ear pain tinnitus vertigo

nasal obstruction epistaxis hoarseness sore throat

disturbance of taste

Remarks: ______________________________________

Respiratory dyspnea chest pain hemoptysis cough back pain

Remarks: ______________________________________

Cardiovascular chest pain palpitation PND orthopnea

easy fatigability shortness of breath

Remarks: ______________________________________

Gastro-Intestinal poor appetite dysphagia odynophagia nausea

vomiting hematemesis abdominal enlargement

Bowel Elimination: Regular: ___________ Irregular: ______________

diarrhea constipation abdominal pain

flatulence steatorrhea melena hematochezia

Remarks: ______________________________________

Genitourinary Dysuria Anuria Polyuria Oliguria Hematuria

Incontinence Dribbling Urinary Frequency

flank/suprapubic pain passage of stone discharge

discharges Remarks: ____________________________

Musculoskeletal

muscle pain joint pain & Stiffness swelling

bone deformity weakness atrophy contractures

restriction of motion

Remarks: ______________________________________

Neuropsychiatric syncope seizures weakness or paralysis headache

tremors loss of memory depression delirium

hallucination Remarks: __________________________

Endocrine weight change heat or cold intolerance polyuria

polydypsia polyphagia abnormal growth

Remarks: ______________________________________

Hematologic easy bruisability easy fatigability pallor

Remarks: ______________________________________

======PHYSICAL EXAMINATION=======

GENERAL SURVEY

Body Built: _____________________________________

Level of Consciousness

Awake and Alert Conscious Coherent

Lethargic Obtunded Stuporous Comatose

Best Response: _________________________________

Mood or Affect

Calm Apathetic Anxious Depressed

Sedated Combative Paranoid

Oriented to: time place person

Speech

Clear Incomprehensible Slurred Aphasic With difficulty Mute Speech delay

Remarks: _____________________________________

Motor Status

Ambulatory Plegia: ( )Right ( )Left

Paresis: ( )Right ( )Left

Gait: __________________________________________

Posture: _______________________________________

Grooming: _____________________________________

In Cardio-Pulmonary Distress?: No Yes

VITAL SIGNS and ANTHROPOMETRIC

MEASUREMENTS

Supine Sitting Standing

B.P. L: L: L:

B.P. R: R: R:

CR: ___________ bpm RR: __________ cpm

PR: ___________ bpm Temp: ________ °C °F

Weight: _____ kg lbs Height: ____ ft cm inch

Waist Circumference: _____ cm inch BMI: ________

REMARKS: _____________________________________

INTEGUMENTARY (Please note/describe/ mark noted skin lesions, edema, body weakness,

identifying marks, fractures, deformities/ abnormalities, palpable lymph

nodes and other important details on the diagram.)

Color: ________________

Texture: _________________________________________

Lesions: _________________________________________ Nailbeds: no clubbing no swelling; Others: __________

Presence of hair: ______________ Capillary Refill: ___sec

Remarks: __________________________________

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HEAD, EYES, EARS, NOSE and THROAT

Head

Normo Micro with lumps/depressions/tenderness

Temporal Artery: palpable non-palpable

Others: _________________________________________

Hair and Scalp

evenly distributed receding hairline bald

alopecia smooth dry

with areas of scaliness/lumps/lesions: _______________

Remarks: _______________________________________

Face

Symmetrical facial movement asymmetrical movements

involuntary movements Lesions: __________________

Deformities: none present: _______________________

Remarks: ______________________________________

Eyes

Eyebrows:color_____________ distribution_____________

Eyelids:

Eyelashes: _______________________________________

Sclera: white icteric/ jaundice Others: ____________

Conjunctiva: pink pale reddened with lesions

Cornea: opacities etc: ____________

Iris: color/contour: ________________________________

Pupil: brisk sluggish pinpoint fixed dilated

non reactive non delineated

Pupil Size: R: _____ mm L: ______ mm

Use of corrective lenses/glasses: No Yes: __________

Visual Acuity: ____________________________________

Visual Field: _____________________________________

Fundoscopic Exam: ________________________________

Other Remarks: ___________________________________

Ears

Outer ear aligned with outer canthus of the eye

ears symmetrical assymetrical: __________________

discharge: ___________________________________

Pain (auricles/mastoid): none present: ______________

Auditory Canal: __________________________________

_______________________________________________

Otoscopic Exam: __________________________________

_______________________________________________

Hearing Tests: ___________________________________

_______________________________________________

Other Remarks: ___________________________________

Nose

Symmetrical Septum intact and in midline

No discharge With discharge: specify: ___________

Rhinoscopy: _______________________________________

Paranasal Sinuses: non tender tender: ______________

Other Remarks: ___________________________________

Oral Cavity

Lips: moist dry with lesions: ________________

Teeth: complete: _____ incomplete dentures, etc

dental condition: ________________________________

Oral mucosa: moist dry with lesions: __________

Gingiva: moist dry with lesions: ________________

Tongue: with deviation: _________

with lesions: _________________________________

Uvula: midline ation/s: ______________________

Tonsils: not inflamed inflamed, Grade: ____________

Posterior Pharynx: ________________________________

Other Remarks: ___________________________________

Neck

Skin: ____________________________________________

Architecture: _____________________________________

Muscle Tone: _____________________________________

Trachea: intact and in midline with deviation: ________

Lymph nodes: non palpable palpable: _____________

Thyroid Gland: not visibly enlarged enlarged

Remarks: ______________________________________

CHEST and LUNGS

Thorax: Normal/Elliptical Funnel Chest Barrel Chest

Pigeon Chest Flail Chest A:P Ratio: _______

Remarks: ______________________________________

Chest Expansion: Symmetrical Asymmetrical

Chest Lagging IC Retractions/Bulging

Remarks: ______________________________________

Breathing

Even Uneven Orthopneic: # of pillows: _______

Labored Dyspneic Shallow Deep

Use of Oxygen via: _____________________________

Remarks: _______________________________________

Tactile Fremitus:

Increase/Decrease:_____________________

Others: subq. crepitus tenderness

Remarks: ______________________________________

Percussion: Resonant Hyper-resonant Dull Flat

Remarks: ______________________________________

Breath Sounds

Normal Crackles/Rales Rhonchi Stridor

Wheezes Remarks: ____________________________

whispered pectoriloquy

Remarks: ______________________________________

Breast: Symmetrical Asymmetrical

ulceration

Findings: ______________________________________

______________________________________________

Nipples: discoloration

scaling discharge depression/flattening ulceration

Remarks: ______________________________________

Other Remarks: _________________________________

CARDIOVASCULAR

JVP: ____ cm sternum R.atrium Degree angle:______°

Jugular Vein: : _____________

Carotid: ___________________ No Bruit With Bruit

Precordium: Adynamic Dynamic: _________________

Ectopic Pulsations: none present: _________________

Apex Beat: 5th

ICS Left MCL <2.5cm >2.5 cm

Displaced: ___________________________________

Palpation: Thrust Heaves Lifts

Cardiac Auscultation

regular Irregular: ___________________________

weak bounding

with Pacemaker: ______________________________

S1, Loud at: ____________ S2, Loud at:____________

S3: ___________________ S4: ___________________

Cardiac Murmurs: _______________________________

______________________________________________

______________________________________________

Other Findings: _________________________________

______________________________________________

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ABDOMEN

Contour: Flat Globular Scaphoid Protuberant

Symmetry: ______________________________________ Skin Findings: striae scars spider angioma

dilated vessels visible mass

Remarks: _____________________________________

Colostomy, specify: ______________________________ Visible Pulsations: ___________________

Visible Peristalsis: ___________________

Umbilicus: inverted everted

Bowel Sounds: _______ per minute at: RLQ

Normal Hyperactive Hypoactive Absent

Bruits: _____________________________

Area of Tympanism: RLQ RUQ LUQ LLQ

Area of Dullness: RLQ RUQ LUQ LLQ

LIVER

Liver Span: _______cm MCL or _______cm MSL

Liver Tenderness: _________________

Remarks: ______________________________________

SPLEEN

Traube’s Space: tympanitic dull

Spleenic Tenderness: ______________

Remarks: ______________________________________

KIDNEY

non palpable palpable: ________________________ CVA Tenderness: : ____________

Remarks: ______________________________________

Tone: Soft Firm Rigid/Board-like Tender

Other Remarks: ___________________________________

Palpable Mass: _____________________

Other Remarks: ___________________________________

Other Palpable Organs: __________________________

Remarks: ______________________________________

-----------------SPECIAL EXAMINATIONS--------------------

Murphy’s Sign Direct Tenderness Blumberg Sign

Markle Sign Rovsing’s Sign Psoas Sign

Obturator Sign Cutaneous Hyperesthesia and Allodynia

Subcutaneous crepitus Bulging Flanks Shifting Dullness

Fluid Wave Puddle Sign Ruler Test

EXTREMITIES

Hands, wrists and fingers:

Thenar, Hypothenar:

Nodules/Pain/Swelling: PIP __________

Deviation: one ulnar radial others: ____________

Motion: FROM restricted with pain o/little mov’t

OTHERS: ________________________________________

Forearm and Elbow: symmetrical uneven: __________

Radius, Ulna: palpable others: ___________________

Nodules/Pain/Swelling:____________________________

Atrophy/Hypertrophy: none present: ______________


OTHERS: ________________________________________

Arms and Shoulders: symmetrical uneven: __________




OTHERS: ________________________________________

Spine:




OTHERS: ________________________________________

Hips and Thighs:




OTHERS: ______________________________________

Knee:



Crepitus: none present: ________________________


OTHERS: ______________________________________

Ankle and Feet:



Crepitus: none present: ________________________


OTHERS: ______________________________________

Toes and Soles:




OTHERS: ______________________________________

NEUROLOGIC EXAMINATION

Cerebrum:

Level of Consciousness

Awake and Alert Conscious Coherent

Lethargic Obtunded Stuporous Comatose

Best Response: _________________________________

Mood or Affect

Calm Apathetic Anxious Depressed

Sedated Combative Paranoid

Follows simple commands: Yes No

Oriented to: time place person

Intact Memory:

Can Do: simple math calculations abstract thinking

appropriate moral judgment

Cerebellum:

Posture: _________________________________________

Tremors: one present

Able to do: Finger-to-Nose Test Rapid alternating mov’t

Heel-to-shin Test

Rhomberg’s Test: negative positive

OTHERS:________________________________________

CN ASSESSMENT FINDINGS

I

II

II, III

III, IV, VI

V

V, VII

VII

VIII

IX, X

XI

XII

Motor Exam

Symmetrical Movements:

Atrophy:

Fasciculations:

Muscle Strength: RUE____ RLE____ LUE____ LLE____

OTHERS:________________________________________

Sensory Exam

Intact Sensory:

stereognosia graphestesia

Sensory Test: RUE____ RLE____ LUE____ LLE____

OTHERS:________________________________________

Reflexes

DTR: intact symmetrical brisk normoreflexia

Babinski:

RUE____ RLE____ LUE____ LLE____

Meningeal Exam

Nuchal Rigidity Brudzinski Sign Kernig Sign

----------------------------------------------------------by: KLPR

medical health examination form

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