PEDIATRIC MEDICAL HISTORY PAST MEDICAL HISTORY Mother’s pregnancies: G_P_ (_ _ _ _) Feeding History

Previous illness Date/age of patient Attitude toward Cause of First year

No. Duration
Informant: Chicken pox pregnancy termination Breastfed
Relation to Patient: Measles 1 Duration
Reliability: German measles 2 Frequency
Mumps 3 Supplementary feedings
GENERAL DATA Primary complex Weight gain
Name: Miscarriages:
Asthma
Age: Abortions: Milk formula
Others
Sex: Brand name
Nationality: SOCIAL HISTORY Preparation
Religion: HEA Occupation Dilution
Surgeries
Birthday: Manner of preparation
How long Father
Birthplace: Where When Why Amount taken
confined Mother
Present Residence: Weight gain
Housing and living conditions:
No. of admissions in present hospital: Solids
No. of household members:
Date of admission: Age Weaning foods Manner of
No. of persons sleeping/sharing in patient’s room: Administration
Time of admission: started used prep
Accidents and injuries
NOI Character of family:
CHIEF COMPLAINT
POI Family relationships:
Reason for admission:
Duration of complaint: DOI
TOI Water supply:
Toilet facilities: Vitamins and minerals supplementation
HISTORY OF PRESENT ILLNESS Brand Dose Frequency
Medications Garbage disposal:
Nature:
Date of onset: Name of
Dosage Frequency Route Indication Prevalent diseases in neighborhood:
Time of manifestation by periods PTA: drug
Description of each manifestation:
PERSONAL HISTORY
Progress of disease in chronological order:
Prenatal History Over a year
Negative findings:
Description of mother’s pregnancy: Dietary pattern
History of infection: Weight gain
Hospitalizations Complications: Description of present appetite
How long Medications:
Previous hospitalizations/consultations for present illness: Where When Why
confined Exposure to teratogens: Growth and Development History
Diagnosis made by previous doctors:
Assess all aspects of development; month/year skills were performed
No. of Diagnostics Meds with Up to 1 year
Trim Place Compli
checkup & results dose&freq Regarded Sat briefly
1st Smiles Creeped
Medications
Hypersensitivity Reactions/Allergies: 2nd Turned head Pulled up
Generic Name Dose Duration of tx
3rd Held head Cruised
FAMILY HISTORY Rolled over Walked with support
Age Physical/mental health Natal History Transferred objects Stood alone
Father Duration and circumstance of labor:
Mother Analgesia or anesthesia: From 1-3 years
Chronological sequence of events leading to CC/admission: Period of gestation: Walked alone Daily routine
Siblings
Hospital or home delivery: Handedness Sleep
Location: Manner of delivery: Used sentences Play
Quality: Type of presentation: Toilet training Relationship to family
Size of family:
Severity/Quantity: Instrumentation: Behavior disturbances
Important Diseases in family:
Timing: Birth weight:
Setting: Difficulties: From 4-12 years
Illness in the family similar to the patient’s illness
Exacerbating factors: School placement and adjustment
Cancer
Relieving factors: Postnatal History Specific attitudes
Heart dse
Associated manifestation: Apnea Convulsions Specific disabilities
TB
Diabetes Cyanosis Pallor Daily routine
Hypertension Jaundice Other unusual S/Sx Sleep
Anemia Play
Hemophilia Spontaneous cry:
Thalassemia Oxygenation/Type of resuscitation:
Rheumatic fever Medications:
Mental illness Congenital defects:
Behavior PERSONAL HISTORY OF ADOLESCENT PATIENTS Time spent
Sleeping habits INTERVAL HISTORY Watching TV
Toilet training If previously been in hospital: PRENATAL HISTORY Playing
Enuresis Condition of child from time of discharge to time of readmission Using computer/internet
Thumb sucking BIRTH HISTORY
Nail biting Drug
Breath-holding POSTNATAL HISTORY Prohibited drugs
Temper tantrums ADOLESCENT HISTORY Friends use drugs
Masturbation Home FEEDING HISTORY Details of drug use
Destructive Relationship with: How & why he started using drugs
Aggressive Parents IMMUNIZATION HISTORY What drugs
Shy Siblings Frequency
Submissive Companions MENSTRUAL HISTORY Amount
Happy Neighbor Menarche Sources
Difficult Intervals Effects
Education Duration
Immunizations History School performance Amount Sexuality
Date/age at Relationship with: LMP Questions on appearance / changes in body
Site Route Complications
admin Teachers Problems Sexual orientation
BCG Classmates Medications In a relationship
OPV Others Typical date
DPT Extracurricular activities PUBERTAL CHANGES Sexually active
Measles Age at onset Age of onset
Hepa B Activities Boys Girls Frequency
Weekend Scrotal changes Genital changes No. of partners
Hepa A
Outside school Penile changes Breast budding Contraceptives
MMR
Pubic hair Pubic hair Paternity/Pregnancy
HIB
Drug intake/Addiction STD
Typhoid
Illegal drugs GROWTH AND DEVELOPMENT HISTORY Physical/Sexual abuse
Varicella Substance
Others Suicide Depression
PSYCHOSOCIAL HISTORY
Sexual Contact Home Sad
REVIEW OF SYSTEMS Unmotivated
Present living arrangements
Special senses Smoking Hopeless
Recent changes in relationships
Visual Lonely
Patient and parents
Hearing Violence Why?
Patient and siblings
Smell How to resolve issues
Between parents
Taste Groups/Gangs Anything in family that patient would like to change? Thoughts of hurting self/others
Feels Seriousness
Education/Employment Need for referral/counseling
Respi
Currently in school?
Cough Spirituality
Favorite subject
Colds Belief in supreme being
Average grade in last eval
Difficulty of breathing Problem with classmates/teachers Church
Ever been suspended/expelled? How often
CV With whom
Employed?
Chest pain
Palpitations
Eating Behavior
Eating habits
GIT
Food preference
Appetite
Eating problems
Vomiting
Dietary history
Constipation
Diarrhea
Activities
Activities after school
GUT
Spare time
Bladder control
With whom does he spend time?
Dysuria
Close friends
Friends attending school?
Neuromuscular
Hobbies
Convulsions
Interests
Weakness
Abnormal gait
 PEDIATRIC PHYSICAL EXAMINATION Chest and Lungs NEURO EXAM Cerebellar Functions
Symmetry Finger-to-nose test
Name Expansion deformities Mental state Heel-to-shin test
Age Type of respiration Level of consciousness Rapid rhythmic alternating movements
Gender Masses Higher intellectual functions Gait
Areas of tenderness Language Heel-toe walk
Date of assessment Tactile fremitus Praxis Tandem walk
Time of assessment Dullness or resonance Grapho-motor and visuo-motor functions Climbing stairs
Ward / OPD / NICU Comparative breath sounds Laterality Running
Adventitious sounds (crackles, rhonchi, wheezes) Hopping
General Appearance Cranial Nerves Skipping
Nutrition and development Heart I – smell familiar scent (coffee, tobacco) Romberg test
Color responsiveness Location of apical impulse II – visual acuity
Evidence of stress Presence of thrill or heave visual fields
Activity and behavior Rate and rhythm fundi
Quality of sounds III, IV, VI – extraocular movements
Vital Signs Presence of murmurs (location, transmission, grade, change with tracking movements
HR position or exercise) ptosis
RR pupillary sizes
BP Abdomen reactivity to light
Temperature Contour (scaphoid, distended, or flat) V – sensory – light touch
Visible or engorged vessels temperature
Anthropometric Measurements Peristalsis pain
Weight (kg) Masses corneal stimulation
Height/Length (cm) Tenderness motor – muscles of mastication
Waterlow classification for wasting and stunting Frequency and pitch of bowel sounds VII – smile
Head circumference (percentile) Examination of inguinal canal show teeth
Chest circumference (percentile) close eyes or frown
Abdominal circumference (percentile) Genitalia VIII – cochlear – hearing tests
Male: “ballpen click”
Skin Phimosis Weber test
Color Patency and location of external urethral orifice Rhinne test
Rashes Location of testes vestibular – balance and orientation in space
Lesions Circumcise IX, X – palatal movements
Scars Discharge uvular position and deviation
Birthmarks Growth of pubic hair gag reflex
Capillary refill time Female: swallowing
Turgor Labia XI –shrug shoulder against resistance
Mongolian spots Clitoris move head against pressure exerted on one side while palpating the
Café-au-lait Hymen opposite SCM
Vaginal discharge XII – Protrude the tongue
HEENT Growth or pubic hair
Shape of head and face Motor findings
Hair (amount, color, texture) Rectum Gross – muscle tone
Scalp Sphincteric tone bulk power
Sutures Size and contents of vault abnormal movements
Fontanels (open or closed, bulging, flat or depressed) Masses or tenderness Fine – writing
Sclera Presence of blood on examining finger figure drawing
Conjunctiva
Pupils Extremities Sensory findings
Cornea Pulses Crude sensations (pain, temperature and touch)
Otoscopic findings Muscle spasm or atrophy Vibration
Nose & throat findings Weakness or paresis Localization
Presence of stridor Joint abnormalities 2-point discrimination
Varicosities
Neck Limitation of movement Reflexes
Supple or rigid Inflammation Deep tendon reflexes (ankle jerk, mandibular jerk)
Local masses Bowing Superficial reflexes (abdominal and cremasteric)
Thyroid Flat feet Plantar responses
Lymph nodes (size, location, mobility and consistency) Nailbeds Pathologic reflexes