Eyes

PEDIATRIC HISTORY and P.E. □ Pain □ Use of glass/lenses

□ Redness □ Lacrimation/Discharge
Date of Interview: ____________________________
□ Blurred vision □ Diplopia
Time of History: ________________
Informant: __________________________________ Ears
Relationship to the Patient: ____________________ □ Hearing problem □ Ear pain
□ Itching □ Ear ringing (Tinnitus)
Reliability: [ good ] [ fair ] [ poor ]
□ Discharge (color/consistency): ____________
Nose
GENERAL DATA □ Frequent colds □ Itchiness
Patient’s Name: _________________________________________ □ Nasal stuffiness/congestion □ Nosebleeds (Epistaxis)
□ Nasal discharge
Age: ______ Sex: ______
Birthday: _______________ Birthplace: ____________________ Mouth and Throat
Address: _______________________________________________ □ Mouth sores □ Sore throat
Nationality: _____________ Religion: ______________________ □ Bleeding gums □ Dysphagia
□ Toothache □ Hoarseness of voice
Occupation: __________________________
Date of Admission: ____________________ Neck
Time of Admission: ____________________ □ Pain □ Stiffness
□ Lumps □ Swollen glands
No. of times admitted at RIMC: ____________
Respiratory
CHIEF COMPLAINT □ Chest pain □ Dyspnea
________________________________________________________ □ Cough □ Frequent colds
□ Sputum (color/quantity): ___________________________
HISTORY OF PRESENT ILLNESS Cardiovascular
□ Chest pain □ Palpitations
Onset: _________________________________________________ □ Orthopnea □ Dyspnea on exertion
Duration: _______________________________________________ □ Cyanosis □ PND
□ Easy Fatigability □ Fainting spells
Frequency: ______________________________________________
Gastrointestinal
Location: _______________________________________________ □ Nausea □ Jaundice
Quality: ________________________________________________ □ Vomiting □ Hematemesis
□ Abdominal pain □ Dysphagia
Radiation: ______________________________________________ □ Hematochezia □ Diarrhea
Severity: ________________________________________________ □ Melena □ Constipation
□ Hemorrhoids □ Stool: ________________
Precipitating Factors: _____________________________________ □ Fecal incontinence (Encopresis) □ Pica
Palliative Factors: ________________________________________ □ Passage of worms

Previous Treatment for the Problem: _______________________ Renal

□ Dysuria □ Urinary Retention
Associated Signs and Symptoms: □ Nocturia □ Incontinence
________________________________________________________ □ Polyuria □ Urinary Frequency
________________________________________________________ □ Oliguria
□ Enuresis/Bed-wetting (day/night?)
Additional Notes:
In Males:
_________________________________________________________
□ Reduced caliber of force of stream
_________________________________________________________
□ Hesitancy
______________________________________________________
□ Dribbling
Genitalia
REVIEW OF SYSTEMS □ Pain □ Swelling
General □ Ulcers □ Itching
□ Fever □ Poor oral intake □ Discharge (characteristics): ___________________
□ Weight gain/loss □ Irritability Peripheral Vascular
□ Chills □ Fatigue □ Leg cramps □ Leg Claudication
Cutaneous Endocrine
□ Rash □ Pruritus □ Polydipsia □ Polyphagia
□ Pigmentation □ Dryness □ Cold/Heat Intolerance □ Excessive sweating
□ Lumps
Head Musculoskeletal
□ Headache □ Lightheadedness □ Muscle weakness □ Stiffness
□ Dizziness □ Syncope □ Backache □ Joint swelling
□ Muscle pain □ Joint pain
□ Limitation of movements
Neurologic Medical Problems for any blood-relative Disease
□ Paralysis □ Numbness
Age and Date of
□ Tremors □ Seizures Relationship to Px
Dx
□ Memory Loss □ Weakness
Cancer
Hematologic HPN
□ Easy bruising □ Bleeding Diabetes
□ Pallor TB
Psychiatric/Behavioral Heart Disease
□ Sleep problems □ Behavioral changes Stroke
□ School failures □ Mood changes Kidney
□ Nervousness □ Depression Arthritis
□ Anxiety □ Hallucinations Blood Disorder
Asthma
PAST MEDICAL HISTORY Epilepsy
Mental Disorder
Allergies: Galbladder dse
Food: ________________________________________________
Medications: _________________________________________
BIRTH & MATERNAL HISTORY
Pollen/Animals/Others: ________________________________
Mother’s age at delivery: ________ OB Score: G___ P____ (T-P-A-L)
Childhood Illness: Exposure (Infection/Drug/Chemical/Alcohol/Smoke): ___________
□ Rheumatic Fever □ Polio
Nutrition: __________________________________________________
□ Chicken Pox □ Measles
□ Mumps □ Asthma Overall Maternal Health: _____________________________________
Others: ____________________________________
Birth History
Blood Transfusions
□ Preterm: ___ wks AOG □ Term □ Post-term ___ wks AOG
Date: ____________________
Delivery (NSVD/CS): ________________
Where: __________________
Where (Home/Hospital/Lying-in/Others): __________________
Surgical Procedures:
Birth wt: ____________ Attendant: ______________
Date: ________________________________________________
Type of Operation: ____________________________________ Neonatal History

Purpose: _____________________________________________ APGAR: ____________ Ballard Score: _____________

Previous Hospitalizations: Resuscitation done? _______________

Date Cause Hospital Treatment Complications: _____________________________________________
Congenital Abnormalities: ____________________________________
□ Cyanosis □ Jaundice □ Pallor □ Good cry

Feeding History
□ Breastfeeding Duration: ________________________
□ Bottle-feeding Duration: ________________________
FAMILY HISTORY □ Complimentary Duration: ________________________
Parents
Father: ___________________ Mother: ____________________ MENSTRUAL HISTORY
Age: __________ Age: __________ Menarche: ___________________________________________________
Interval: Menstrual Cycle: □ Regular □ Irregular: every __________
Occupation: _______________ Occupation: _________________
Duration: ___________________________________________________
State of physical/mental health: ____________________________ Amount/# pads per day: _______________________________________
History of Consanguinity: □ Yes □ No Type of pads: ________________________________________________
With or without dysmenorrhea: □ Yes □ No
Siblings Medication: _________________________________________________
Other associated symptoms: ___________________________________
# of siblings: _____________________________________________
Subsequent menses: __________________________________________
Age: ____________________________________________________ LMP: _______________________________________________________
State of health: __________________________________________
IMMUNIZATION HISTORY Varicella □ 12-15 months

VACCINE AGE/DOSE REMARKS □ 17 months-6 years

BCG □ 0-2 weeks □ 6-18 years (Catch up)

Hep B □ 0-2 weeks Hepa A □ 12 months-2 years

□ 4-8 weeks □ 2-18 years (Catch up)

□ 10-16 weeks HPV □ 9-18 years

*Ask for the patient’s Baby book if it is available
If unable to elicit detailed information:
Did the patient have a vaccination RECENTLY?
□ 14 weeks-12 months
Route: _________________________________________________
□ 12 months-18 years (Catch
Location: _______________________________________________
up)
Reactions/Side effects: ____________________________________
DTaP / Tdap □ 6-8 weeks
□ 10-16 weeks NUTRITIONAL HISTORY
□ 14 weeks-6 months No. of meals per day: ________________________________________
□ 12-18 months (combination Food preference: ____________________________________________
with IPV-HiB) Coffee/Tea/Soda Intake: ______________________________________
□ 4-6 years (combination Nutritional Supplement: _____________________________________

with IPV)
DEVELOPMENTAL MILESTONES
□ 6-18 years
Milestone Age
Hib □ 6-8 weeks Social smile (2 mos) ____________
□ 10-16 weeks Head control (3 mos) ____________
□ 14 weeks-6 months Roll-over (5 mos) ____________
IPV/OPV □ 6-8 weeks Sit w/ support (7 mos) ____________

□ 10-16 weeks Sits alone (10 mos) ____________

Stands (12 mos) ____________
□ 14 weeks-6 months
Grasps spoon (15 mos) ____________
PCV □ 6-8 weeks
1-5 years old
□ 10-16 weeks □ phobia □ sleep disturbance □ rides tricycle
□ night terror □ toilet training □ throws ball
□ 14weeks-6months
□ parallel play □ stands on one foot □ walks backward
□ 12-15months □ unbuttons button□ knows family name □ laces shoes
□ names colors □ asks 300-400 questions/day
□ 15months-5 years (Catch
6-11 years old
up)
□ school performance: _________________________________
RV □ 6 weeks-8 months
□ Is there a delay in speech? □ Recognize and draws all shapes?
Influenza □ 6 months-18 years
□ Interest in God? □ Interest in Competitive games?
(YEARLY) □ Able to count backwards? □ Using both hands independently?
Measles □ 9-12 months □ Able to tell time correctly? □ Hero worship? □ Writes legibly?
JEV □ 9 months-18 years □ Constantly active □ Well-mannered with adults

MMR □ 12-15 months

□ 16 months-6 years PERSONAL HISTORY
□ 6-18 years (Catch up) Highest Educational Attainment: ______________________________
Smoking Habits:
□ non-smoker □ smoker □ ex-smoker
No. of sticks/packs per day: ________________ = _______ pack years
Year started: ______________ Year quitted: ____________
Alcohol Consumption
□ never □ occasionally □ daily □ weekly
Alcohol type: _______________________________________________
Amount consumed: _________________________________________
HEADSSSS (10-18 y/o)
Home
Who lives with you? _________________________________________
Do you have your own room? Shares room? _____________________
What do parents do for a living? _______________________________
How are relationships like at home? ___________________________
Can you talk to anyone at home about stress? ___________________
Is there anyone new at home? Has someone left recently? _________
Have you ever run away? _____________________________________
Is there any physical violence at home? _________________________
Education
How are you coping in school? ________________________________
Are you having difficulties in school? ___________________________
Are you having difficulty understanding what the teacher is saying?
___________________________________________________________
Are you having difficulties with concepts? With any particular
subjects? ___________________________________________________
Have you failed in any grade level in previous years? _____________
Have you been skipping classes or been having poor attendance? ___
Are you having difficulty in concentration? _____________________
Are you fidgeting a great deal while in class? ____________________
Do you have poor attention span? _____________________________
Are you able to finish assigned tasks? __________________________
Do you find yourself acting impulsively? ________________________
Do you easily get bored or are you very impatient while at class? ___
Do you find yourself mentally restless? Have you become lazy or
unmotivated? _______________________________________________
School/grade performance? ___________________________________
School attendance? __________________________________________
Any years repeated/classes failed? _____________________________
Have you changed schools in the past few years? _________________
Relationship with teachers, employers? _________________________
Tell me about your friends at school: ___________________________
Favorite/Least Favorite Subjects? ______________________________
Future education plans? ______________________________________
Employment
Are you working? □ Yes □ No
if yes, where: _____________________________________________
type of work: _____________________________________________
time of work: ____________________________________________
how much/salary: _________________________________________
How do you get along with people at work? _____________________
Future employment plans? ___________________________________
Activities
What do you do for fun? How do you spend time with
friends? Family? (With whom, where, when?) ___________________
Some teenagers tell me that they spend much of their
free time online. What types of things do you use the
Internet for? ________________________________________________
How many hours do you spend on any given day in
front of a screen, such as a computer, TV, or phone? Do
you wish you spent less time on these things? ___________________
Do you participate in any sports? ______________________________
Books? Music? ______________________________________________
How do you feel after playing video games? _____________________
Drugs
Do any of your friends or family members use
tobacco? Alcohol? Other drugs? _______________________________
Do you use tobacco or electronic cigarettes? ____________________
Alcohol? Other drugs, energy drinks, steroids, or
medications not prescribed to you? ____________________________
Is there any history of alcohol or drug problems in your
family? ____________________________________________________
Does anyone at home use tobacco? ____________________________
Do you ever drink or use drugs when you’re alone? _______________
(Assess frequency, intensity, patterns of use or abuse,
and how patient obtains or pays for drugs, alcohol, or
tobacco.) (Ask the CRAFFT questions)
Sexuality
Sexual Orientation: __________________________________________
Interest for: □ opposite sex □ same sex □ both
Have you ever been in a relationship? □ Yes □ No
Have any of your relationships been violent? ____________________
# of partners: _______________________________________________
Masturbation? ______________________________________________
Sexual contact? _____________________________________________
(Girls) Have you ever been pregnant or worried that you
may be pregnant? ___________________________________________
(Boys) Have you ever gotten someone pregnant or
worried that might have happened? ____________________________
What are you using for birth control? Are you satisfied
with your method? __________________________________________
Do you use condoms every time you have intercourse?
What gets in the way? _______________________________________
Have you ever had a sexually transmitted infection or Who do you talk to when you feel upset about something/ when you
worried that you had an infection? _____________________________
feel really happy about something? ____________________________

Suicide/Depression
SOCIOECONOMIC HISTORY
□ Sleep disorders (usually induction problems, also early/frequent
waking or greatly increased sleep and complaints of increasing Type of residence: ___________________________________________
fatigue) Type of house: ______________________________________________
□ Appetite/eating behavior changes
□ Feelings of 'boredom' # of persons living in the house: ________________________________
□ Emotional outbursts and highly impulsive behavior Working members of the family: ________________________________
□ History of withdrawal/isolation
□ Hopeless/helpless feelings Source/s of funds: ____________________________________________
□ History of past suicide attempts, depression, psychological
counseling ENVIRONMENTAL HISTORY
□ History of suicide attempts in family or peers
□ History of recurrent serious 'accidents'
□ Psychosomatic symptomology Exposure: □ cigarette/smoke □ pollutants
□ Suicidal ideation (including significant current and past losses) Source of drinking water: ______________________________________
□ Decreased affect on interview, avoidance of eye contact--
depression posturing Garbage disposal: _____________________________________________
□ Preoccupation Fecal disposal: _______________________________________________
Pet/s: _______________________________________________________
Safety
Do you feel safe at home? at school? at work? in your neighborhood? Personally gives bath to pets: □ Yes □ No
_____________________________________________ General state of neighborhood: _________________________________
If NO, what makes you feel unsafe? ___________________________
Have you ever been seriously injured? (How?) How PHYSICAL EXAMINATION
about anyone else you know? _________________________________
GENERAL SURVEY
Do you always wear a seatbelt in the car? _______________________ Mood: ______________________________________________________
Have you ever met in person (or plan to meet) with Position: ____________________________________________________
anyone whom you first encountered online? ____________________ Cooperative/Non-cooperative: _________________________________
□ Irritated □ Agitated □ Pleasant □ Coherent
When was the last time you sent a text message □ Alert □ Lethargic □ Oriented to time, place, person
while driving? ______________________________________________ □ In distress? → □ Pale □ Cyanotic □ Injuries
Tell me about a time when you have ridden with a Manner brought in:
driver who was drunk or high. When? How often? _______________ ____________________________________________
Contraptions:
Is there a lot of violence at your home or school? In _________________________________________________
your neighborhood? Among your friends? ______________________
Do you use safety equipment for sports and/or other VITAL SIGNS
physical activities (for example, helmets for biking or Blood Pressure: ________ Interpretation: ________
skateboarding)? _____________________________________________ Cardiac rate: ________ Interpretation: ________
Respiratory rate: ________ Interpretation: ________
Have you ever been in a car or motorcycle accident? Temperature: ________ Interpretation: ________
(What happened?) __________________________________________

Have you ever been picked on or bullied? Is that still a

problem? __________________________________________________
Have you gotten into physical fights in school or your
neighborhood? Are you still getting into fights? __________________
Have you ever felt that you had to carry a knife, gun, or
other weapon to protect yourself? Do you still feel that
way? ______________________________________________________
Have you ever been incarcerated/imprisoned? ___________________

Spirituality
Does your family attend a place of worship? What do you think about
that? _________________________________________________
Do you believe in something outside yourself? ___________________
ANTHROPOMETRICS
Height: ________ Weight: ________ BMI: ________
Recumbent Length (birth to 24 months): ________
Head Circumference (1st 2 years of life): ________
Chest Circumference: ________
Abdominal Circumference: ________
- Infants (Level of umbilicus)
- Older Children (midway between the inferior margin of the
last rib and crest of ilium)
Arm Span (normal arm span = height): ________
Z-Score: ________

INTEGUMENTARY:
Color: ______________________________________________________
Rashes/Lesions: ______________________________________________
□ Bulla □ Cyst □ Macule □ Pustule
□ Nodule □ Papule □ Plaque
□ Vesicle □ Wheal

HEENT
A. HEAD
Trauma: _____________________________________________
Size: ____________________ Shape: ___________________
Tenderness: __________________________________________
Hair and Scalp: _______________________________________
Symmetry: ___________________________________________
Masses: ______________________________________________
 PMI: ____________________________________________________
B. EYES Heaves/Thrills: ___________________________________________
Visual Acuity: Murmurs (Grade, Intensity, Describe):
Far: (R) __________ (L) ___________ _________________________________________________________
Near: (R) __________ (L) ___________ Friction Rub: _____________________________________________
Visual Fields (H-test): __________________________________
Conjunctiva: Color? Discharges? : ________________________ ABDOMEN
Sclera: Color? Discharges? : _____________________________ Inspect:
Distension: ______________________________________________
Vessels: _________________________________________________
C. EARS Striae: __________________________________________________
Symmetry: ___________________________________________ Visible pulsations/Peristaltic movements: _____________________
Ear canal patency: _____________________________________
Discharges: ___________________________________________ Auscultate:
Otoscopic examination: ________________________________ Bowel sounds: ____________________________________________
o Infants (Pull pinna downwards and posteriorly) □ High-pitched (Bowel obstruction, diarrhea)
o Older Children (Pull pinna upwards and back) □ Absent (Ileus)
Rinne Test:
(R) AC __________ BC ___________ Percussion:
(L) AC __________ BC ___________ □ Tympanitic □ Dullness
Weber Test: __________________________________________ □ Rebound tenderness

D. NOSE GENITALIA
Nares patency: ________________________________________ Inguinal region:
□ Nasal flaring? : ______________________________________ □ Lymphadenopathy □ Hernia
Discharges: ___________________________________________ □ Masses
Septum position: ______________________________________ Male:
□ Sinus tenderness? : __________________________________ □ Prepuce easily retractable □ Undescended testis
Female:
E. MOUTH and THROAT □ Discharges □ Lacerations
Tonsils: _____________________________________________
□ Enanthem □ Vesicles □ Ulcers TANNER STAGING:
□ Pale lips □ Cleft Palate □ Cleft Lip

F. NECK
Supple: ______________________________________________
Symmetry: ___________________________________________
Range of Motion: _____________________________________
Tenderness: __________________________________________
Venous engorgement: __________________________________
Lymph Nodes: ________________________________________
Size: _________
Tenderness? : _________
Consistency: _________
Thyroid Gland: _______________________________________

CHEST AND LUNGS

Deformities: _____________________________________________
Retractions: ______________________________________________
Masses: __________________________________________________
Chest lag: ________________________________________________
Vocal fremitus: ___________________________________________
Breath sounds: ___________________________________________

CHEST AND HEART

Precordial bulges: ________________________________________
Visible pulsation: _________________________________________
ANUS and RECTUM CN 8:
(*Position patient on Left lateral decubitus with legs flexed) □ Hears finger rub / Whispered voice
Patency: _________________________________________________ Rinne: _________________ Weber:__________________
□ Bleeding □ Masses
Possible parasites: _________________________________________
CN 9, 10:
EXTREMITIES Palate and Uvula: ___________________________________________
Deformities: ____________________________________________ □ Gag reflex
Palpate for Pulses:
CN 11:
□ Shoulder shrug (against resistance)
□ Head rotation (against resistance)

CN 12:
□ Atrophy □ Fasciculation
Position with protrusion: ___________________________________

REFLEXES

Deep tendon
□ Biceps □ Knee □ Triceps
□ Brachioradialis □ Ankle

Superficial
□ Abdominal □ Cremasteric

Infants
Joints/Range of Motion: ___________________________________ □ Grasp □ Sucking □ Moro
□ Rooting □ Tonic neck □ Babinski
SPINE
Deformities: _____________________________________________
Scoliosis: ________________________________________________

NEUROLOGICAL EXAMINATION
Orientation
□ Name □ Date □ Day □ Month □ Year
□ Hospital □ Ward □ City □ Country
LOC: GCS
E: _________ V: _________ M: _________

Object Recognition
□ Agnosia □ Praxis □ Perception
□ Astereognosis

CRANIAL NERVE EXAMINATION

CN 1:
□ Identify odorant

CN 2:
Visual acuity: _________ Visual field: _________
Fundoscopy: _________

CN 3, 4, 5:
Size and Shape of Pupil: ____________________________________
Extra-Ocular Muscles: _____________________________________
□ Paresis □ Nystagmus
□ Saccades □ Diplopia
PERRLA: _________________________________________________
Lyceum-Northwestern University – FQDMF
CN 5: College of Medicine
□ Ophthalmic □ Maxillary □ Mandibular Department of Pediatrics
□ Jaw clench □ Corneal reflex
Dr. Perez | Cuison | Cabrera
CN 7 History and PE (v2.0 – Series of 2018)
□ Eyebrow elevation □ Forehead wrinkling
□ Eye closure □ Smiling □ Cheek puffing