This medical evaluation form collects information about a patient's medical history, presenting complaints, past medical history, drug and treatment history, family history, and physical exam findings. The physical exam includes a general exam noting vital signs and appearance, as well as detailed exams of the head, neck, chest, abdomen, extremities, and neurological system. The form is used to document a comprehensive medical evaluation.

1. MEDICAL EVALUATION PERFORMA
History No:__________
Name _______________________________________________ Age______________ Sex ______
PatientNo: __________________ Department________________________
Date_______________________
Name ofDuty Doctor _______________________________________________________________
PresentingComplaints:
History of PresentingIllness:

2. PAST MEDICAL/SURGICAL HISTORY:
YES NO YES NO YES NO
DM HBV/ HCV PsychiatricDisorder
HTN TB Smoking
Asthma Migraine Epilepsy
Drug History Allergies Gynecological /_____________________
Obstetrical History
Operational History:____________________________________________________________________
BloodTransfusions:____________________________________________________________________
Others_______________________________________________________________________________
DRUG/TREATMENTHISTORY:
PERSONAL HISTORY:
FAMILY HISTORY:
SOCIOECONOMIC STATUS:

3. Systematic review
CVS:
CNS:
GIT:
RESP:
GENITOURINARY:
ENDOCRINE:

4. GENERAL PHYSICAL EXAMINATION:
. Name: age: gender: DOA:
. General Physical Appearance (Appearance, Physique, Consciousness, Posture
and attitude)
BP mmHg
PULSE RATE /min
BLOOD PRESSURE mmHg
TEMPERATURE
RESPIRATORY RATE
F/C
/min
GCS /15
. Face:
Symmetry:
Color of skin:
Color of sclera: Color of lower conjunctiva:
Color of lips:

5. School of Health Sciences
Cyanosis:
Jaundice:
Pallor:
Periorbital edema:
Proptosis:
Any skin rash:
Facial hair distribution: (hirsutism in case of females)
Parotid gland:
. Mouth:
Teeth hygiene:
Tongue: (color, texture and size)
. Hand:
*Nails:
Clubbing:
Koilonychias:
Splinter hemorrhages:
Leuchonychia:
Pitting of nails:

6. School of Health Sciences
*Fingers:
Osler nodes:
Heberden’s nodes:
Bouchard’s nodes:
Interphalangeal joints:
*Palms:
Palmar sweating:
Palmar erythema:
Dupuytren’s contracture:
*Hand shape, size and any other deformity:
. Neck:
*Thyroid gland
*Neck veins
*Lymph nodes:

7. School of Health Sciences
. Axilla:
*Lymph nodes
. Groin:
*Lymph nodes
.Feet
* Ankleedema:
*Clubbing:
*Koilonychias:
*Cyanosis:
ReferredTo (in case of referral): ______________________ Signaturesof Duty Doctor