M E D I C A L H I S T O R Y- Q C G H

Historian:
Proctor:
History No.
Informant:
Reliability:

Date of History:
Date of Submission:

GENERAL DATA
Name:
Address:
Age:
Birthdate:
Sex:
F
M
Marital Status: Single
Married
Occupation:

Number of admission:
Date of admission:

Place:
Divorce

Widowed

Religion:
Nationality:

CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

Immunizations:
____ BCG
____ DPT
____ Polio
____MMR
____ HIB

Childhood Diseases:
____
____
____
____
____

Typhoid
Influenza/Flu
Pneumococcal
Hepa B
Tetanus

____ Measles (tigdas)

____ Mumps
____ Chicken Pox

Allergies:
Past Illnesses:
Accidents:

Blood Transfusion:

Hospitalizations:
FAMILY

Surgical Operations:

HISTORY
Mother Father Siblings HEREDOFAMILIAL DISEASES

PATERNAL SIDE

MATERNAL SIDE

Cancer
Epilepsy
Kidney Diseases (Cholelithiasis)
Hypertension
Metabolic (DM)
Mental Disorder(BID, MDD, Schiz)
Heart Diseases

PERSONAL & SOCIAL HISTORY

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Educational Attainment:
Occupational Hx:
Nature of work:
# of hours:

Exposure to hazards:
Safety measures used:

Marital Status:
Years Married:
Health status of spouse:
Health status of children:

Age:
Age:
Age:
Age:

Relationship with spouse:

children:
Exposure to STD:

Relationship with
Year:

# and gender of sexual partners:

Whether patient is separated:

Habits:
Sleep pattern:
hours every night
hours nap
Diet:
Fond of eating:
Coffee:
cups per day
Alcohol:
Never
Occasional social
Age:
Drinks to Intoxication:
never
rare
frequent
when alone
rested
Smoking:
sticks/day
pack/years
quit
Age:
Use of drugs:
Hobbies:
Exercise:
Duration:
Living conditions:
Living with:
House:
rooms
windows
door
CR
Source of water supply:
Waste disposal:
OBSTETRICAL HISTORY
Menarche:
Duration:
Amount of flow:
Symptoms:
Interval:
regular
irregular
Every when:
Duration:
days
Amount of flow:
napkin/s per day
Premenstrual symptoms:
Last Menstrual Period:
Menopausal Age:
Hx of taking Contraceptives:
Gravidity & Parity:
Gravidity:
Parity:
Full Term:
(38 weeks up)
Pre-term:
(21-37 weeks)
Abortion:
less 500 gms)
Live birth:
G1
Sex:
MOD:
Place:
Year:
G2
Sex:
MOD:
Place:
Year:
G3
Sex:
MOD:
Place:
Year:
Complications:

(less than 20 weeks,

REVIEW OF SYSTEMS
GENERAL
(-) weakness, (-)
fatigue, (-) weight
change, (-) fever, (-)
chills, (-) sweats
SKIN
HEENT
HEAD
EYES
EARS
NOSE & SINUSES
THROAT (OR MOUTH
& PHARYNX)
NECK
BREASTS
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINA
L

URINARY
GENITAL

MALE
FEMALE

PERIPHERAL

(-) rash, (-) pruritus, (-) pigmentation, (-) lumps, (-) sores, (-) dryness, (-) change in hair & nails
(-) headache, (-) dizziness, (-) light headedness
(-) vision, (-) glasses or contact lenses, (-) pain, (-) redness, (-) itching, (-) excessive tearing,
(-) double vision, (-) blurred vision, (-) spots, (-) specks, (-) flashing lights, (-) glaucoma, (-)
cataracts
(-) hearing, (-) tinnitus, (-) vertigo, (-) earaches, (-) discharge
(-) colds, (-) discharge, (-) itching, (-) dryness, (-) nosebleeds, (-) sinus trouble, (-) pain,
(-)obstruction,
(-) sense of smell, (-) sneezing
(-) pain, (-) dry mouth, (-) hoarseness, (-) sore throat, (-) bleeding gums, (-) dentures (if any & how
they fit),
(-) sore tongue, (-) difficulty of swallowing
(-) lumps, (-) swollen glands, (-) pain, (-) stiffness
(-) Lumps, (-) pain, (-) discomfort , (-) nipple discharge, (-) bleeding , (-) self-examination practices
(-) cough, (-) hemoptysis, (-) dyspnea, (-) pain, (-) wheezing, (-) sputum
(-) heart trouble, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitations, (-) dyspnea, (-)
orthopnea,
(-) paroxysmal nocturnal dyspnea, (-) edema
(-) trouble swallowing, (-) heartburn, (-) appetite, (-) nausea, (-) vomiting , (-) bowel movements
(-) color, (-) size of stools, (-) change in bowel habits, (-) rectal bleeding, (-) melena, (-)
hemorrhoids,
(-) constipation, (-) diarrhea, (-) abdominal pain, (-) food intolerance, (-) excessive belching or
passing of gas.
frequency of urination: (-) polyuria, (-) nocturia, (-) urgency, (-) dysuria, (-) hematuria, (-)
incontinence, (-) stones
(-) Hernias, (-) discharge from or sores on the penis, (-) testicular pain or masses, (-) swelling, (-)
ulcer,
(-) itching, (-) sexual habits and problems, (-) exposure to HIV infection
(-) dysmenorrhea, (-premenstrual tension, (-) vaginal discharge, (-) bleeding, (-) itching, (-) sores,
(-) lumps, (-) sexual habits and problems, (-) exposure to HIV infection
(-) Claudication, (-) varicose veins, (-) past clots on veins

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VASCULAR
MUSCULOSKELETAL
NEUROLOGIC
HEMATOLOGIC
ENDOCRINE
PSYCHIATRIC

(-) muscle or joint pains, (-) cramps, (-) stiffness, (-) sweating, (-) tenderness, (-) limitation of
motion,
(-) trauma, (-) weakness
(-) syncope, (-) blackouts, (-) seizures, (-) paralysis, (+) numbness, (-) tingling or pins or needles,
(-) tremors and other involuntary movements, (-) pain, (-) sensory, (-) memory
(-) anemia, (-) easy bruising, (-) bleeding
(-) cold intolerance, (-) excessive sweating, (-) excessive thirst or hunger, (-) change in glove or
shoe size
(-) nervousness, (-) tension, (-) mood, (-) depression, (-) memory change, (-) suicide attempts (if
relevant)

PHYSICAL EXAMINATION
GENERAL SURVEY
Conscious, coherent, well developed, well nourished, oriented to time, place & person, cooperative, with good
posture, normal gait, no gross deformities, ambulatory, afebrile, not in cardio respiratory distress.
VITAL SIGNS
BP:
RR:

mmHg (R arm)
mmHg (L arm)

Temp:

C (R axilla)
C (L axilla)
o

PR:

SKIN
The skin is brown in color, no pallor, no edema, smooth, moist, warm, elastic, good turgor, no lesions. The hair
is black in color, well distributed. The nail beds are pinkish in color, no clubbing & no swelling of nail fold.
HEENT
CRANIUM
The hair is black in color, abundant, has smooth texture and well distributed. The scalp is not movable along
the cranium, no lesions, no lice, no scaling, no masses and no tenderness elicited upon palpation. The cranium is
normocephalic, symmetrical and has no deformities. No hematomas noted. Sutures are non palpable. Temporal
arteries are not visible but palpable with weak pulsations.
FACE
The face is symmetrical. No noted abnormal facies, no skin lesions and no involuntary movenments. The
patient can also move his facial muscle with ease and has a good facial profile.
EYES
Eyebrows are black in color, thick, well distributed, symmetrical and the growth extends beyond the canthus.
Eyelashes are black, short, no matting and are present in both upper and lower eyelids, no matting of the eyelashes.
Eyelids are free from swelling and lesions. No nystagmus, no ptosis, no enopthalmos no exopthalmos. Palpebral
diameter is ___cm. Conjunctiva is pinkish, no lesions, no edema. Sclera is anicteric. Cornea is transparent and clear, no
opacities, no ulcerations. Iris is round and black in color. The pupils are round and symmetrical, measure 4 mm in
diameter, equally reactive to light. No tenderness on the eyeballs upon palpation. Visual acuity of ______ on Jaegers
chart. Extraocular muscles are intact.
EARS
Ears are symmetrical, triangular in shape, no deformities, no tenderness, no lesions. External auditory canal
are patent. The walls are pinkish in color, no discharges.
NOSE
Nose is symmetrical, no flaring of the ala nasi, no secretions, no epistaxis. Nasal septum is in the midline, no
perforations. Frontal and maxillary sinuses are non tender, and positive for transillumination test.
MOUTH AND THROAT
Lips are symmetrical, pink in color, moist, smooth, no lesions, no pigmentation. Buccal mucosa is pinkish,
moist, no lesions. Tongue is in the midline, pink in color, no deviation, no lesion. Complete set of teeth without dental
carries. Uvula is in the midline. Tonsils are pinkish in color, not enlarged.
NECK
Skin is brown in color. Neck is in the midline, symmetrical, no deformity, no deviation. Trapezius and
Sternocleidomastoid muscles are well developed, no deviations, no tenderness. Thyroid is palpable, visible and
movable upon swallowing. No lymphadenopathy. No neck vein engorgement.
CHEST AND LUNGS
Skin is brown in color, subcutaneous blood vessels are hardly visible, no lesions, with good muscle
development. Lateral diameter is greater than the AP diameter. Chest is symmetrical & no bony deformities, no
intercostals retractions or bulging, no narrowing or widening of ICS, no lagging. Equal chest expansion. No tenderness,
no masses. Equal tactile fremitus. Resonant on all lung field. Clear breath sounds, no rales, no wheezes, no egophony
or whispered pectoriloqy
CARDIOVASCULAR
Adynamic precordium, no visible pulsations, no neck vein distention, no thrills, no heaves. Apex beat is at 5 th
ICS LMCL on supine position. No murmurs, no bruit noted. S1 is best heard at the apex and S2 is best heard at the
base. Pulses are weak, regular rate and normal rhythm on both sides.
ABDOMEN
Abdomen is flat, circumference is ___ cm at the level of the umbilicus, no lesions, no striae, no superficial
veins, no post operation scar, inverted umbilicus, symmetrical, no visible peristalsis or pulsations. Bowel sounds of ___
Page 3 of 4

per minute. No bruit. No tenderness, no masses, no organomegaly. All quadrants are generally tympanitic. Liver span
of ___ cm at RMCL. No costovertebral angle tenderness, negative for Murphys Sign, Psoas Sign, Rovsings sing,
Obturator Sign, no direct and rebound tenderness, negative for fluid wave test, no shifting dullness and negative for
puddle sign
SPINE & EXTREMITIES
No swelling, no masses, no joint pains, no crepitus, no edema, or any gross deformities. No clubbing of fingers,
without limitations on the range of motions of the upper and lower extremities.
NEUROLOGIC EXAM
Cerebral:
Patient is conscious, coherent, reactive to verbal stimuli, good memory, can recall remote, recent, immediate
events. Good speech, oriented to time, place and person, with good judgment.
Cranial Nerves:
C.N. 1: able to smell cigarette on both nostrils with both eyes closed.
C.N. 2 : able to read 7mm newsprint at distant of 2 feet, both eyes tested separately.
C.N. 3,4,6: full range of movement of EOM
C.N. 5 & 7: (+) corneal reflex
C.N. 7: can wrinkle forehead and able to feel pain sensation on the face.
C.N. 8: can hear whispered commands both ears tested separately, no nystagmus
C.N. 9 & 10: (+) gag reflex, uvula at midline, intact voice production
C.N. 11: can shrug both shoulder
C.N. 12: tongue at midline
Cerebellar:
Patient able to do the finger to nose test, heel to shin test and alternating supination and pronation with
accuracy and speed. Normal gait.
Meningeal:
(-) Kernig's sign, (-) Brudzinski's sign, (-) Nuchal rigidity
Autonomic:
(-) fecal incontinence, (-) urinary incontinence

Motor

DTR

Sensory

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