MEDICAL HISTORY TAKING

 Introduce yourself
 Interview purpose, ease patient
 Give a periodic summary after each section
 Give a closing statement, allow patient to ask questions (confirm or disagree, thank the patient)
 Eye-contact
 Ask necessary data
 Appropriate open-ended and leading questions
 Interest and concern
 Organization, coherence and control of interview

GENERAL DATA

• Name:

• Age:

• Sex:

• Handedness:

• Civil Status:

• Nationality:

• Race:

• Religion:

• Occupation:

• Place of Birth:

• Residence:

• Number/Time of admission:

CHIEF COMPLAINT: (how can I help you?; what brings you here?)
HISTORY OF PRESENT ILLNESS (HPI)

• Onset of symptoms

• Duration

• Continuity/intermittency

• Character

• Location and Radiation

• Intensity

• Progression and course

• Aggravating Factors

• Precipitating factors

• Relieving factors

• Medications

• Associated symptoms

• Risk factors

• Previous consultations: who/where did you consult? Did they give medication? Did they do rests? What
were the results? Compliant or non-compliant and reasons.

• Pain/Symptom

o Onset (when did it start?)

o Position (where is?)

o Quality (character: how does it feel? depth: is it on the surface or deep inside -superficial/deep?)
o Relationship (to function or position)
o Radiation (does the pain move to other places?)

o Relieving factors (what do you physically do to feel better?)

 o Severity (how does it affect your daily activities? Does it affect your sleep? Scale from 1-10?)

o Timing (mode of onset: is it abrupt or gradual? progression: is it continuous or intermittent

what is the frequency and nature?)

o Treatment (have you had this treated? - what? Dose? Frequency? how did you feel after?)

o Temporal-ness (how long does the it last?)

PAST MEDICAL HISTORY

▪ Previous hospitalizations

▪ Previous surgeries

▪ Accidents of injuries

▪ Current Medications (generic and brand names, dosages, duration, compliance)?

▪ Allergies

▪ Immunizations (tetanus toxoid, tetanus-diphtheria-pertussis/TDaP, Hepatitis B/HepB, Influenza,

Pneumococcal, COVID- primary doses, secondary doses and boosters including dates)?

▪ Similar illness

▪ Other Illness: e.g. hypertension, diabetes mellitus, heart disease, asthma, cancer, others.

FAMILY HISTORY

▪ Similar illness

Other Illness: Heredofamilial disease e.g. hypertension, diabetes mellitus, heart disease, kidney disease, lung disease,

asthma, cancer, others. Communicable disease e.g. hepatitis and tuberculosis, Multifetal pregnancies , Congenital

anomalies

PERSONAL AND SOCIAL HISTORY

 ▪ Education

▪ Usual daily activities

▪ Housing

▪ Financial status

▪ Availability of family and friends

▪ Diet

▪ Risky habits (smoker, alcoholism, drugs)

▪ Risk factors (occupational/environmental)

▪ Employment/Source of income if unemployed

▪ Sexual orientation and habits

▪ Alternative healthcare habits

▪ Lifestyle (how would you describe your overall lifestyle in terms of your health?)

SEXUAL HISTORY

• Coitarche (when was your first sexual contact?):

• Number of sexual partners (how many sexual partners have you had in your life?):
• Regularity of sexual intercourse (how often do you have sex?):
• Satisfaction (do you enjoy your experience when you have sex?):
• Signs and symptoms (do you experience bleeding after sex or pain during sex?):
• Last sexual contact (when was the last time you had sex?):

BIRTH AND MATERNAL HISTORY

Nabanggit po ba ng inyng magulang kung kayo po ay planado noong 

Ipinagbuntis?
Did your parents mention if you were planned when
pregnant?

Nabanggit po ba ng nanay nyo kung nagkaroon sya ng sakit at 

komplikasyon habang kayo’y ipinagbubuntis?
Did your mother mention if she had an illness and complications while she was pregnant with you?
 Alam nyo po ba kung ipinanganak kayong normal delivery o cesarean?
Do you know if you were born normal delivery or cesarean?

Nagkaroon po ba ng komplikasyon sa panganganak ang inyong nanay?

Did your mother have complications during childbirth?

MENSTRUAL HISTORY

Menarche (when was your first menstruation?-year and month)

Interval (how many days are between your menses? Irregular or regular?)

Duration (how long do your menses usually last for?)

Amount (how many pads/tampons do you use? How soaked are the pads: mild, moderate, heavy?)

Symptoms (did you experience pain, headaches, dizziness, nausea? If so, did you take any medications?)

 Ask the same questions for subsequent menstruations.

 Do you experience any irregularities in your menstruation?

OBTERICAL HISTORY

Gravidity (how many times have you been pregnant, including your current pregnancy?):

Parity (how many times have you given birth after 20 weeks?):

Term (how many of your babies have you given birth to after 37 weeks?):

Pre-term (how many of your babies have you given birth to before 37 weeks?):

Abortion (have you ever had an abortion: miscarriage, ectopic pregnancy or hydatidiform mole?):

Living (how many of your children are currently living?):

Gravida Birthdate Manner of Place of Gender Birthweight Complications*

delivery* delivery
*If CS, mention if it’s primary or repeat, type of incision (Low transverse, classical) and the indications.

*Mention foetal or maternal (antepartum, intrapartum or postpartum) complications.

GYNECOLOGICAL HISTORY

 Infections/Diseases (have you ever had a sexually transmitted infection or disease?):

o e.g. syphilis, chlamydia, candida, gonorrhoea, genital herpes, HPV, hepatitis?
 Surgery (have you ever had a surgery done to your uterus, ovaries, vagina or breasts?)
o e.g. TAHBSO, endometrial curettage, labiaplasty etc.
 Pap smears with dates- year and month (when was your last pap smear? What was the result? Where you
prescribed any medications?

FAMILY PLANNING HISTORY

 What family planning methods have you used?

 IF contraceptive:
o What type of contraception do you use? (generic and brand name)
o How long have you used it for?
o Did you experience any side effects?
 e.g. headache, dizziness, nausea, vomiting etc.
o IF already stopped: why did you stop and when did you stop?

REVIEW OF SYSTEMS
General Health ( )weight changes ( )body weakness
( )decreased appetite ( )easy fatigability ( ) poor
activity ( ) body malaise/weakness

Integumentary ( )rashes ( )erythema ( )pallor ( )blisters

( )mass ( ) pruritis ( ) hair loss
( ) discolouration ( ) skin eruptions

Hematopoietic ( ) easy bruising ( ) easy bleeding ( ) paleness

Head and neck ( ) headache ( ) dizziness ( ) mass

( ) distended veins ( ) muscle stiffness
Eyes ( ) blurring ( ) eye pain ( ) discharge ( ) redness
( ) tearing ( ) use of glasses

Ears ( )Otalgia (pain? Hearing loss?) ( ) tinnitus

(ringing or bussing in the ear?) ( ) difficulty
in hearing ( ) vertigo ( ) discharge

Upper Respiratory Tract (Nose) ( ) watery discharge ( ) epistaxis (nose

bleeding?)
( ) obstruction ( ) frequent colds
Mouth ( ) sore throat ( ) mouth ulcers ( ) teeth
problems (. ) dental caries
( ) bleeding ( ) toothache ( ) hoarseness

Breasts ( ) masses ( ) change in appearance

Respiratory Tract ( ) haemoptysis ( ) dyspnoea ( )pleuritic chest

pain
( ) tachypnoea ( ) cough ( ) shortness of breath
Cardiovascular System ( )palpitations ( ) angina ( ) varicose veins
( ) orthopnoea ( ) cyanosis ( ) nail clubbing
( ) chest pain ( ) fainting spells
(difficulty in breathing when lying down?)

Gastrointestinal ( ) vomiting ( ) nausea ( ) food intolerance

( ) dysphagia ( ) nausea ( ) diarrhoea
( ) constipation, ( ) abdominal pain ( ) emesis
( ) hematemesis ( ) jaundice ( ) melena (dark
stool?)
( ) haematochezia (bloody stools?)

Nutrition

Urinary Tract ( ) dysuria ( ) urinary incontinence (lack of

bladder control?) ( ) flank pain ( ) frequency
( ) discharge ( ) bleeding ( ) haematuria

Genitals/Sexual ( ) swelling ( ) pain ( ) rash ( ) pruritis

Menses/Obstetrics and ( ) irregular menses ( ) painful menses

Gynecology ( ) dyspareunia
Musculoskeletal ( ) joint pains ( ) muscular pains ( ) fractures
( ) oedema ( ) myalgia ( ) joint swelling
( ) limited motion
Nervous System ( ) double vision ( ) lack of balance
( ) weakness in any extremity or part of the face
( ) syncope ( ) one-sided weakness
( ) convulsions/seizures
( ) mood changes ( ) sleep problems
 ( ) memory loss

Endocrine System ( ) polyphagia ( ) polyuria ( ) polydipsia

( ) temperature intolerance ( ) diaphoresis

Allergies ( ) medications ( ) pollen

Emotional/Behavioural ( ) psychological/emotional problems

( ) eating problems ( ) personality changes
( ) behavioural changes

PHYSICAL EXAMINATION
GENERAL SURVEY
 Development (well, fairly, poorly)
 Nutrition (well, fairly, poorly
 Apparent state of health (well/ill and weak-looking)
 Level of consciousness (alert, lethargic, obtunded, stuporous, comatose)
 Coherence (coherent or incoherent)
 Orientation (time, place, person)
 Signs of distress (no signs, dyspnoeic, tachypnoeic, orthopneic: mild, moderate, severe; in pain, others)
 Height and built (only report abnormalities)
 Weight (only report abnormalities)
 Skin colour and obvious lesions
 Dress, grooming and hygiene
 Facial expression (appropriate, inappropriate or other)
 Odours of the body or breath
 Posture, gait, motor activity (ambulant, weak but ambulant, bedridden, others)
 Appearance as to stated age

VITAL SIGNS
 BP=
 HR=
 RR=
 Temp=
 O2=

NUTRITIONAL STATUS
Anthropometrics
 Weight =
 Height =
 BMI =
 % Weight loss or gained =
 Waist circumference (midway between lowest rib and iliac crest) =
  Hip circumference (maximum circumference over the buttocks) =
 Waist: Hip ratio =

Nutritional Survey
 Subcutaneous fat loss (inspect: buccal fat pads, clavicle and chest, skin pinching of subcutaneous fat)
 Muscle atrophy (palpate: deltoid, bicep, quadriceps, calf muscles)
Overall assessment: well/fairly (mild to moderate loss)/poorly (severe loss) nourished

SKIN
General characteristics (general survey of the skin)
Inspection
 Colour, oedema
Palpation
 Temperature (back hand to palms and arms), turgor (finger pressure), degree of moisture (back hand to legs,
palms, soles), hardness (“pinch test)
Presence of absence of lesions
 Primary skin lesions: macules or patches, papules, plaques, nodules, tumours, vesicles, bullae, wheals, pustules
 Secondary skin lesions: scales, crusts, fissures, erosions, ulcers, scars, atrophy
Skin appendages (hair and nails)
 Amount of hair (no hair loss, hypertrichosis/hirsutism), hair structure (hair shaft abnormalities: easy breakage,
nodules), hair colour, infestation
 Nail plate (dystrophy/deformities), nail bed (lesions), nail folds (lesions)
Mucosae
 Oral/nasal/conjunctival/genital/perineal/perianal (no lesions)

Sample PE findings
A. Skin • Colour fair, no jaundice, no pallor, no erythema, no rashes, no lesions, no
hypo/hyperpigmentation, warm to touch, no localized/generalized oedema
good skin turgor: prompt/instant return of skin after pressing, no
anhidrosis/hypo-/hyperhidrosis, skin is soft and resilient
B. Head • Normocephalic, no abnormal swelling, with black smooth hair, no mass,
C. Eyes • Pink palpebral conjunctivae, non-icteric sclerae, no exophthalmia, pupils 2-3mm
- penlight equally briskly reactive to light and accommodation (EBRTLA), no preferential
- ophthalmoscope gaze to either side

• Fundoscopy : (+) ROR

D. Ears • Grossly normal, symmetrical, supple pinnae, no mass, no ear discharge, no

- otoscope masses palpated in the post-auricular and mastoid areas
• Otoscopy not done

E. Nose • Patent nares, midline septum, no alar flaring, no nasal discharge, no mass
- nasal speculum
F. Mouth and • Pink, moist lips and buccal mucosa, midline tongue, normal uvula, no tonsillo-
Throat pharyngeal congestion, no exudates, no mass
- tongue depressor
- gloves
G. Neck • Midline trachea, no hyperpigmentation, no mass, no cervical
lymphadenopathies
H. Chest and Lungs • Inspection: symmetrical chest expansion, no subcostal or intercostal retractions
 - stethoscope • Palpation: equal tactile and vocal fremitus on all lung fields (“tres-tres”)
• Percussion: resonant on all lung fields
• Auscultation: bronchovesicular breath sounds, no rales no wheezes

I. Breasts • Inspection: symmetrical, smooth skin, hyperpigmented areolae and

Montgomery glands, everted nipples, with dilated superficial vessels, no oedema
• Palpation: firm, no mass, no nipple discharge, no axillary lymphadenopathy

J. Heart • Inspection: adynamic precordium, no visible pulsations, apex beat at the 5 th ICS
- stethoscope LMCL
• Palpation: no heaves (palm) or thrills (finger tips and finger pads)

• Auscultation: S1>S2 at base, S2>S1 at apex, normal rate, regular rhythm, no

murmurs
K. Abdomen • Inspection: globular, dark brown linea nigra, brown striae gravidarum
(Obstetric) • Palpation: Fundic height = __ cm, EFW = __
kg No uterine contractions
Leopold’s maneuver:
LM1: large nodular
mass
LM2: small irregular mobile parts on the
maternal left, hard resistant structure on the
maternal right LM3: hard ballotable mass LM4:
head is not engaged
• Auscultation: FHT = __ bpm best heard at the RLQ with regular rhythm

Abdomen • Inspection: flat / full / globular, symmetrical, no distention, no organomegaly,

(Gynecologic) (+/-) silver striae gravidarum, no scars, inverted triangle hair pattern
- stethoscope • Auscultation: normoactive bowel sounds (15 per minute)

• Palpation: soft/rigid, no visible pulsations, no organomegaly, no fluid wave, no

succussion splash, no direct tenderness, no rebound tenderness, no inguinal
lymphadenopathy, no inguinal mass
• Percussion: tympanitic on all quadrants

L. Genitalia • External Genitalia:

(Obstetric) o Inspection: normal hair distribution on mons and labia majora, no lice,
no erythema, no excoriation, no discoloration, no
hypo/hyperpigmentation, no vesicles, no ulcerations, no pustules, no
warty growths no neoplastic growths, no pigmented nevi, no
varicosities, no scars, symmetrical labia majora and minora, clitoris is
bulb shaped measuring 1 cm, hymen is intact/imperforate/open,
perineum gapes/remains closed, perineal body measures __ cm, no
hemorrhoids
o Palpation: urethra palpated with no discharge, no mass at 5 and 7
o’clock position, no bulging of the anterior and posterior vaginal walls

• Speculum examination: Not done

• Internal examination: cervix closed, uneffaced, intact membranes, cephalic,
station - 1
Genitalia • External Genitalia:
(Gynecologic) o Inspection: normal hair distribution on mons and labia majora, no lice,
 no erythema, no excoriation, no discoloration, no
hypo/hyperpigmentation, no vesicles, no ulcerations, no pustules, no
warty growths no neoplastic growths, no
pigmented nevi, no varicosities, no scars, symmetrical labia majora and
minora, clitoris is bulb shaped measuring 1 cm, hymen is
intact/imperforate/open, perineum gapes/remains closed, perineal
body measures __ cm, no hemorrhoids
o Palpation: urethra palpated with no discharge, no mass at 5 and 7
o’clock position, no bulging of the anterior and posterior vaginal walls

• Speculum examination: no vaginal erythema, no lesions, no discharge; cervix

smooth, pinkish, external os is round/slit-like/stellate, (+/-) Nabothian cysts, no
cervical ectropion, no lesions, no discharge, no blood
• Internal / Bimanual examination:
o Cervix closed, firm
o Corpus is anteverted / anteflexed, retroverted / retroflexed /
midposition, mobile / fixed, smooth /irregular/ knobby, small/ enlarged
to _ wks AOG, no tenderness
o Normal ovaries / no adnexal masses / right/left adnexal mass cystic /
firm, moveable / fixed, measuring __ cm, inferior pole palpated at the
cul de sac
o Tender/nontender nodulations in the posterior cul de sac, with / no
blood per examining finger
• Rectovaginal examination: rectal vault collapsed, smooth rectovaginal septum,
no nodulations in the uterosacral ligament
M. Extremities • Full and equal pulses
• No edema, no varicosities
• No gross deformities, no swelling, no clubbing, no cyanosis

N. Spine • Spine midline, with lordosis, no gross deformities (scoliosis, kyphosis)

O. Neurologic exam • Refer to neuro exam notes…

ASSESSMENT
 After the interview: logical impression, explain signs and symptoms gathered from patient

PLAN OF MANAGEMENT
 After the interview: comprehensive including diagnostics, therapeutics and supportive plan. Must be
appropriate and must follow practice guidelines

CASE DISCUSSION
 After the interview: quality discussion of the clinical condition
 CASE MANAGEMENT AND FAMILY REPORTING

SUMMARY OF THE DISEASE CONDITION

 Short history
 Working diagnosis
 Plan of management
 Current health status

FAMILY PROFILE AND STRUCTURE

 Sociodemographic
 Economic
 Environmental

LIST AND DESCRIBE FAMILY

Ilan kayong sa inyong pamilya?

How many are you in your family?

Sino-sino ang nakatira ngayon sa inyong bahay?

Who lives in your house now?

Isa-isahin po natin sila

Let's list them one by one…

MOTHER 
▪ Name 
▪ Age
Civil status 
▪ Personality 
▪ Role in family 
▪ Job
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

FATHER 
▪ Name 
▪ Age 
Civil status
▪ Personality
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

SIBLING 1 
▪ Name 
▪ Age 
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*
 SIBLING 2 
▪ Name 
▪ Age 
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death* 
SIBLING 3 
▪ Name 
▪ Age 
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

SIBLING 4 
▪ Name 
▪ Age 
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

SIBLING 5 
▪ Name 
▪ Age 
Civil status
▪ Order 
▪ Personality
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

Kanino po kayo pinakaclose? Sinong lagging 

tinatakbuhan tuwing may problema?
Who are you closest to? 
Who are you not so close to?
Who runs away whenever there is a problem?

FAMILY LIFELINE
 History of the family (where and how the family began up until now)
o Focus on significant experiences in chronological order (marriages, births, deaths, illnesses: health
seeking behaviour, perception of health, job/study opportunities, travel, milestones etc.)
  Emphasize the application of the physical, psychological, social, spiritual factors
 Questions:
o When was the family established?
o When were the children born?
o Where there any marriages and deaths (or major illnesses) that have occurred in the family? When?

FAMILY GENOGRAM
Remember:
 Exact dates for: births, marriages, separations, divorce, deaths (including cause), significant life events
 Indicate who lives in the same house together and their address
 Names of the two families

GRANDMOTHER-PATERNAL 
▪ Name 
▪ Age
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household
▪ Relationship to patient 
▪ Diseases/Cause of Death*

GRANDFATHER-PATERNAL 
▪ Name 
▪ Age
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death* 

GRANDMOTHER-MATERNAL 
▪ Name 
▪ Age
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
▪ Diseases/Cause of Death*

GRANDFATHER-MATERNAL 
▪ Name 
▪ Age
Civil status
▪ Order 
▪ Personality 
▪ Role in family 
▪ Job 
Financial contribution to the family 
▪ Relationship to members of household 
▪ Relationship to patient 
 ▪ Diseases/Cause of Death*

FAMILY LIFE CYCLE STAGE

 After the interview based on information gathered:
o Stages: unattached adult, newly married couple, family with young children, family with adolescents,
launching family, family in later years.

PSYCHODYNAMICS
 After the interview based on information gathered:

ASSESSMENT OF FAMILY FUNCTION

FAMIILY MAP
 Reflect family relationships and interaction patterns based on information elicited in the family profile and
genogram

APGAR
Part I
 Ask the patient to fill in the table
 Interpret the APGAR score
Part II
 Ask the patient to fill in the table
 Interpret the APGAR score

SCREEM
 Ask the patient to fill in the table
 Interpret the SCREEM score

FAMILY CIRCLE
 Draw a large circle on a piece of paper that represents the family
 Ask patient to draw variable sized circles within or outside the big circle, that either touch each other or are
far apart (representing the patient and other significant persons)
 Patient must then explain the diagram they made
 Interpret
o How do each of the members relate to each other?
o Are there any conflicts between the family members?

FAMILY AND INDIVIDUAL REACTION TO ILLNESS (Assessment of impact of illness)

 Identify: health, emotional, socio-economic problems
 Patient understanding:
o Do you know the cause of your disease/symptoms?
o Do you know how it comes about?
o If your disease/symptoms continue do you know what will happen to you?
o Do you know what you need to do to get better?
o What do you think/feel about your symptoms/diagnosis? (fearful, hopeful, disheartened, angry,
depressed, neutral)
 o Why did you think it was important to consult?
o What are your concerns about your illness?
o What do you think will be the major problems you will face and how do you plan to handle them?
 Family understanding:
o What do you think/feel about your family member’s symptoms/diagnosis? (fearful, hopeful,
disheartened, angry, depressed, neutral)
o How do you plan to support him/her?
 Additional questions:
o What changes in the family function have occurred since the diagnosis?
o Have there been any shifts in family roles and responsibilities?
o What is the effect on the family financial resources?

IDENTIFIED PROBLEMS AND RECOMMENDATIONS FOR THE FAMILY

 After the interview: make sure they are concrete and relevant to the identified problems of the family.

WELLNESS PLAN FOR THE WHOLE FAMILY

 After the interview