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    Pediatric History - Template

    Uploaded by

    Jolaine Vallo
    This document contains a pediatric history and physical examination form. It collects information about the patient's chief complaint, history of present illness, review of systems, personal history including birth history, past medical history, immunizations, family history, and socioeconomic and environmental history. The form is used to document the initial evaluation of a pediatric patient.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Pediatric History - Template

    Uploaded by

    Jolaine Vallo
    157 views5 pages
    This document contains a pediatric history and physical examination form. It collects information about the patient's chief complaint, history of present illness, review of systems, personal history including birth history, past medical history, immunizations, family history, and socioeconomic and environmental history. The form is used to document the initial evaluation of a pediatric patient.

    Original Title

    PEDIATRIC HISTORY - TEMPLATE

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    This document contains a pediatric history and physical examination form. It collects information about the patient's chief complaint, history of present illness, review of systems, personal history including birth history, past medical history, immunizations, family history, and socioeconomic and environmental history. The form is used to document the initial evaluation of a pediatric patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    157 views5 pages

    Pediatric History - Template

    Uploaded by

    Jolaine Vallo
    This document contains a pediatric history and physical examination form. It collects information about the patient's chief complaint, history of present illness, review of systems, personal history including birth history, past medical history, immunizations, family history, and socioeconomic and environmental history. The form is used to document the initial evaluation of a pediatric patient.

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    © All Rights Reserved
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    FJEUSTMED2019

    PEDIATRIC HISTORY - INITIAL

    I. GENERAL DATA

    Name: Nationality: Sex:


    Age & Bday: Birthplace: Religion:
    Address: Date of admission:
    Informant: Relation to patient: Reliability:
    Date of interview:

    II. CHIEF COMPLAINT (in patient’s words, translate to medical term if possible,
    NOT diagnosis but a symptom/group of symptoms)

    III. HISTORY OF PRESENT ILLNESS


    (Chronology, OLDCARTS, OPQRST, Re-admissions, Consultations,
    Medication, Significant positives and negatives)

    FJEUSTMED2019
    FJEUSTMED2019

    IV. REVIEW OF SYSTEMS


    General □ Weight change GU □ Hematuria
    □ Fever □ Dysuria
    □ Chills □ Frequency
    □ Malaise/Activity level □ Enuresis
    □ Change in appetite □ Edema
    □ Change in sleep pattern □ Discharge
    □ Delay in growth □ Itching
    S/H/N □ Rash Endo □ Breast abnormality
    □ Itchiness □ Palpitations
    □ Color change □ Cold/heat intolerance
    □ Hair change □ PPP
    □ Abnormal nail
    HEENT □ Headache Neuro/ □ Tremors
    □ Dizziness Psych □ Sleep problems
    □ Visual difficulty □ Convulsions
    □ Lacrimation □ Paralysis
    □ Eye redness □ Mental deterioration
    □ Ear discharge □ Personality/behavioral
    □ Nasal discharge/colds changes
    □ Epistaxis □ Memory loss
    □ Toothache □ Eating problems
    □ Sore throat □ Mood changes
    □ Bleeding gums □ Temper outbursts
    □ Taste disturbance □ Hallucinations
    CV □ Orthopnea MSK □ Muscle pain
    □ Cyanosis □ Joint pain
    □ Easy fatigability □ Bone pain
    □ Fainting spells □ Stiffness
    □ Chest pain □ Limping
    Respi □ Cough Hema □ Pallor
    □ Dyspnea □ Bleeding
    □ Sputum □ Easy bruising
    □ Hemoptysis
    □ Wheezing
    GI □ Vomiting Additional notes:
    □ Hematemesis
    □ Melena
    □ Hematochezia
    □ Dysphagia
    □ Food intolerance
    □ Indigestion
    □ Diarrhea
    □ Constipation
    □ Abdominal pain
    □ Jaundice

    FJEUSTMED2019
    FJEUSTMED2019

    V. PERSONAL HISTORY
    For Patients <2y/o
    A. GESTATIONAL HX D. FEEDING HX
    Age of mother during pregnancy: Type of Feeding
    OB score: □ Breastfeeding
    Duration of pregnancy: □ Formula
    Health/Nutrition/Infection/Rx/Radio: □ Mixed
    If not breastfed, reason:

    Frequency:
    Formula used:
    Dilution and amount per day:

    B. BIRTH HX Complementary Feeding


    Term: Age introduced:
    Manner of delivery: Type of food:
    □ NSD
    □ CS
    Person attending to delivery Consistency:
    /Location: Frequency:

    Birth weight: Usual Food Intake


    Meals (emphasis on 5 food groups):

    C. NEONATAL HX

    ACI/RENI:

    Food Intolerance:

    APGAR score:
    Multivitamin/Iron Supplements:
    7 or greater : normal Dose and Frequency:
    4 to 6 : borderline
    3 or less : severely depressed

    FJEUSTMED2019
    FJEUSTMED2019

    For Patients 2-20 years old E. DEVELOPMENT/BEHAVIORAL


    D. FEEDING HX HX
    Appetite: For patients 6-11 y/o
    School performance:

    Usual Food Intake


    Meals (emphasis on 5 food groups):

    Tanner Rating:

    ACI/RENI:
    E. DEVELOPMENT/BEHAVIORAL
    HX
    For 10-20 y/o
    HEADSSFIRST

    Food Intolerance:

    Multivitamin/Iron Supplements:
    Dose and Frequency:

    E. DEVELOPMENT/BEHAVIORAL
    HX
    For patients 1-5 y/o
    Modified Development Checklist:

    Dental eruption:

    FJEUSTMED2019
    FJEUSTMED2019

    F. PAST ILLNESSES
    Age Severity/Hospital Stay/Description Complications
    Contagious
    Diseases
    (MMR, Pox)
    Medical
    Illnesses

    Operation

    Injury

    Allergy:

    VI. IMMUNIZATION HISTORY & TUBERCULIN TEST


    Immunization Age given Place given (Health Untoward reactions
    given center/doctor’s clinic)

    VII. FAMILY HISTORY


    Parents: Father Mother Familial Illnesses/anomalies
    Age
    Occupation
    State of
    physical/ mental
    health VIII. SOCIOECONOMIC HX
    (Living, source of income)
    If +, age and
    cause of death

    Siblings: IX. ENVIRONMENTAL HX


     Number (Cigarette exposure,
     Ages pollutants, garbage, sewage,
     State of health water source)
     If +, age and
    cause of death

    FJEUSTMED2019

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