I.

PATIENTS PROFILE
A. GENERAL DATA
NAME:
_________________________
AGE: __________
SEX:____________
G__P__(__ __ __ __) AOG:
_________
RACE: _________
RELIGION:_______
CIVIL STATUS:
___________________
OCCUPATION:
___________________
ADDRESS:
_______________________
_______________________________
BDAY:
__________________________
BPLACE:
________________________
DATE OF ADMXN:
________________
PLACE OF ADMXN:
________________
B. MENSTRUAL HX
MENARCHE
Age: _____ Duration:
_____________
Character of Flow: Light/ Mod/
Heavy
Pads/day:______________________
_
SUBSEQUENT MENSES
Regular:_______________________
__
Pads/day:
_______________________
Duration:
_______________________
Interval:
________________________
Days of Menstrual Cycle:
___________
Associating Symptoms:
Dysmennorhea: _____
PainScale: ____
Intervention:
____________________
_______________________________
_
Meds: (Name/

OB HISTORY
MENOPAUSE
Age: ______ HRT used:
____________
_______________________________
Menopausal S/s:
- Hot flashes ( )
- Irritability ( )
- Fatigue ( )
- Others:
__________________
_______________________________
_______________________________
Post Menopausal Bldg
(Days/Char):
_______________________________
C. OBSTETRIC HX
OB SCORE: G__P__(__ __ __ __)
PREVIOUS PREGNANCIES
Deliveries: (Date/ Place/ AOG/
Hrs of Labor/ Mode of
Delivery/ Wt & Sex of Infant/
Cx)
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Abortion: (Date/ AOG/ D/C for
8wks , 8wkscomplete
abortxn / Spontaneous or
Induced)
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Other abN pregnancies:
(Ectopic/ Gestational
Trophoblastics Dates & Mgt)
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
PRESENT PREGNANCY:

D. PRENATAL HX
Date 1st Prenatal Check up
(AOG):
_______________________________
Prenatal Caregiver:
_______________
Regularity of Check up:
____________
LABS: (Date & Results)
UTZ:
___________________________
_______________________________
Others:
________________________
_______________________________
_______________________________
_______________________________
_______________________________
Medications:
____________________
_______________________________
_______________________________
_______________________________
_______________________________
Vaccinations: (include date)
_______________________________
_______________________________
_______________________________
Illness: (include Interventions/
Meds)
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Date of Quickening (AOG):
_________
_______________________________
Wt gained:
_____________________
Usual BP:
_______________________
Date of Last Prenatal Check
up: _____
E. CONTRACEPTIVE HX
( ) Pt does NOT use
( ) If Pt use:
Type Used:
_____________________
Year Used:
______________________
Duration of Use:

Dose/Time/Response)
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
Intermenstrual Bldg
(Days):_________
Ammenorhea (>6mos):
____________
R/t contraceptives:
_______________
Other Assoc S/s:
- Breast tenderness ( )
- Inc Appetite ( )
- Irritability ( )
- Others:
__________________
_______________________________
_
Int:
____________________________
_______________________________
_
_______________________________
_
LMP:
___________________________
PMP:
___________________________
AOG:
___________________________
G.
PAST HX
CHILDHOOD ILLNESS
( ) Measles (tipdas)
( ) German Measles
( ) Chickenpox (hangga)
( ) Mumps (Bayuok)
( ) Small pox (Bulutong)
( ) Others:
______________________
_______________________________
IMMUNIZATIONS: (date)
( ) BCG
_________________________
( ) HEP B
________________________
( ) DPT
_________________________
( ) OPV

LMP:
__________________________
EDC:
___________________________
AOG:
__________________________
H. PERSONAL AND
SOCIAL HX
MARITAL STATUS
Duration of Marriage:
_____________
Work of Partner:
_________________
Health of Partner:
________________
Compatibility:
___________________
HABITS
Alcohol ingestion:
________________
- Since:
___________________
- # of bottles:
______________
- Frequency:
_______________
- Cut down:
_______________
- Annoyed:
________________
- Guilt feelings:
_____________
- Eye opener:
______________
- Stop:
____________________
Smoking:
- Since:
___________________
- Packs/day:
______________
- Frequency:
_______________
- PACKS/ YR
= (Age now - Age start )
x(pack/day)
Sedatives:
______________________
Drugs:
_________________________
Sleeping habbits:
________________
OCCUPATION
Past:
__________________________

_________________
Reason of D/C:
__________________
S/E:
___________________________
_______________________________
F. SEXUAL HX
Coitarche:
______________________
# of Sexual Partners:
______________
Regularity:
______________________
Sexual Interest/ Fnc/
Satisfaction:
( ) Normal
Others:
________________________
Rank in the family:
_______________
SIBLINGS: (Age/ Health/ Meds)
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Heredofamilial Dse:
______________
_______________________________
Hx of Twinning/ Diff Deliveries/
Toxemias of pregnancy/
Congenital Anomaly:
_______________________
_______________________________
II.
CHIEF COMPLAINT
_______________________________
III.
HPI
Onset:
_________________________
Nature/ Char:
___________________
Severity:
_______________________
Location:______________________
_
Aggravating:
____________________
Relieving:
______________________
Meds:
_________________________

_________________________
( ) AMV / MMR
__________________
( ) HiB
__________________________
Others:
_________________________
_______________________________
_
_______________________________
_
ADULT ILLNESS:
MEDICAL:
( )HPN
_________________________
( ) DM
__________________________
( ) BA
__________________________
( ) Ca
__________________________
# of Admxn/ Date/ Place/ due
to/ Dx/ Treatment/ length of
hosp:
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
SURGICAL: (date/place/ dx)
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
Injuries/ Accidents: (date/
place/int)
_______________________________
_

Present:
________________________
Exposure to Occupational
Hazards:
_______________________________
_______________________________
Income & Source:
________________
_______________________________
Hx of travel: (Place/ Date)
_______________________________
_______________________________
_______________________________
_______________________________
I. FAMILY HX
FATHER:
Age: _____ Health:
______________
_______________________________
Meds: (Name/ Dose/
Compliance)
_______________________________
_______________________________
MOTHER:
Age: _____ Health:
______________
_______________________________
Meds: (Name/ Dose/
Compliance)
_______________________________
_______________________________

_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Associating S/S:
__________________
_______________________________
_______________________________
_______________________________
Pertinent Neg:
__________________
_______________________________
_______________________________
Others:
________________________
_______________________________
_______________________________
VITAL SIGNS
TEMP: ___ C, R/L, Axillary,
Oral,Rectal
PR: ___bpm, R/L radial,
regular/ irregular, weak,
thread, strong, forceful,
bounding
RR: ___bpm, regular/ irregular
BP: ___ mmHg, R/L, arm/ leg/
sitting/ supine
HT: _____ WT: ______ BMI:
_______

_______________________________
_
PSYCHIATRIC:
____________________
_______________________________
_
LABS: (Date & Results)
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
_______________________________
_
REVIEW OF SYSTEMS
General. Usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness,
fatigue
Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails
Head, Eyes, Ears, Nose, Throat (HEENT)
Head. Headache, head injury, dizziness, lightheadedness
Eyes. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred
vision, spots, specks, flashing lights, glaucoma, cataracts
Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids
Nose and sinuses. Frequent colds, nasal stuffiness, discharge, or itching hay fever, nosebleeds, sinus trouble
Throat. Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, last dental examination, sore
tongue, dry tongue, frequent sore throats, hoarseness
Neck. Lumps, swollen glands, goiter, pain or stiffness in the neck
Breasts. Lumps, pain or discomfort, nipple discharge, SBE
Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray, asthma,
bronchitis, emphysema, pneumonia, TB
Cardiovascular. Heart trouble, high BP, rheumatic fever, heart murmurs, chest pain or discomfort, palpations,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past ECG or other heart test results
Gastrointestinal. Trouble swallowing, heartburn, appetite nausea, bowel movements, color and size of stools, change
in bowel habits, rectal bleeding or black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food
intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis
Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary
infections, kidney stones, incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling
Genital.
Male hernias, discharge, from or sores on the penis, testicular pain or masses, history of STDs and their treatments,
sexual habits, interest, function, satisfaction, birth control methods, condom use, problems, exposure to HIV infection
Female age at menarche, regularity, frequency, and duration of periods, amount of bleeding, intermenstrual bleeding
or after intercourse, LMP, dysmenorrheal, premenstrual tension, age at menopause, menopausal symptoms,
postmenopausal bleeding, vaginal discharge, itching, sores, lumps, STDs and treatments, number of pregnancies,
number and type of deliveries, number of abortions, complications of pregnancy, birth control methods, sexual
preference, function, satisfaction, problems, dyspareunia, exposure to HIV infection, if born before 1971, exposure to
diethylstilbestrol (DES) from maternal use during pregnancy
Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins
Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected
joints, muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness or limitation in motion or
activity, duration & any history of trauma
Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and
needles, tremors or other involuntary movements
Hematologic. Anemia, easy bruising or bleeding, past transfusions and or transfusion reactions
Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change

in glove or shoe size

Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant
GENERAL SURVEY
Level of consciousness: conscious/alert, confused,
Signs of distress: labored breathing, flaring of ala nasi,
lethargic/somnolent, stupor/semi-coma, comatose
wheezing, coughing, sweating, anxious face,
Mental state & mood: orientation to time, place and
protectiveness of painful parts, fidgety movement
identity, coherent, incoherent, cooperative,
Physical appearance in relation to age: appropriate,
uncooperative, hostile, depressed, apathetic, nervous
younger, older
Gait: ambulatory, non-ambulatory, trunk posture, gait
sequence, arm movement, hemiplegic, steppage, tabetic,
VITAL SIGNS:
parkinsonian, scissors
TEMP=
Posture: normal position, lordosis, kyphosis, scoliosis,
BP=
decorticate rigidity, decerebrate rigidity, opisthotonus
PR=
State of nutrition: underweight, emaciated, cachetic,
RR=
normal, overweight, obese, extremely obese
Habitus/Body build: mesomorphic, ectomorphic,
SKIN:
endomorphic, sthenic, asthenic, hypersthenic
Color, temperature, moisture, texture, mobility and turgor,
Stature/Height
lesions
Involuntary movements: tics, chorea, athetosis, dystonia,
tremors (resting, intention, postural)
NAILS:
Speech: normal, hoarse voice, aphonia, slurred, scanning,
Color, shape and lesions
echolalia
Sexual development : normal, precocious puberty,
HAIR:
hypogonadism, virilism, delayed puberty
Quantitiy, distribution, texture and color