UERM MED 2014 A2

Date of Admission:
Date of Interview:

PATIENT PROFILE
Name: Age:
Date of Birth:
Address:
Previous Address, if any
Reason for transfer
Religion: Nationality:
No. of Admission:
Date of Previous Admission:
Location of Previous Admission:
Reason for Previous Admission:


SOURCE: RELIABILITY:

CHIEF COMPLAINT


HISTORY OF PRESENT ILLNESS

USE BACK PAGE (CLITAA) ^_^

PAST HISTORY

BIRTH HISTORY
OB Score: G__ P__ (T__ P__ A__L__) Age of mother (upon giving birth)
Child’s position in the family: ______
Was this a planned pregnancy? Last Menstrual Period:
Menarche & Coitarche
Any Prenatal care? Where?
How frequent? Who?
Did the mother receive immunizations? Vitamins? (E.g, TT, Folic Acid)
Any morning sickness, food cravings?
Any special practice or doctor’s order they had to follow? (E.g. complete bed rest, not
take a bath, exercise)
Does the mother smoke or drink alcohol?
During the course of pregnancy, any illness? (E.g. spotting)
 What did they do to treat?
 Any medications taken?
What is the type of delivery? How many hours of labor?
IF CS, indication for CS?
Where?
Any complications during the delivery?
Birth Attendant:
Birth Weight: Birth Length:
APGAR score:
Did the child need to be resuscitated?
Any congenital anomalies?
Need for confinement? How long was the stay? Any postnatal care? How often?

UERM MED 2014 A2

FEEDING HISTORY
Was the child breastfed? If no, why not?
Immediately breastfed / not (Why?)?
Duration?
How often? How long is one feeding?
Does the child have good sucking?
Did the mother have good lactation?
Does the child have good appetite?
Was the child on Infant formula? _____ Why? When did it start?
Brand:
How many scoops of formula? Ounces of water?
Are complimentary foods being given? _________ Since when? ________________
What types of food are being given?
Any adverse food reactions/food allergies?
Any vomiting?Any medications / vitamins being taken?
Stool:
Frequency: _______ Consistency: ______ Color: ______
Present Diet:

DEVELOPMENTAL MILESTONE (Pls. Check)
1 month
□Startles □alert to sound
□Regard □identify mother’s voice
& smell
2 month
□Smile □show pleasure with
parents

3 month
□Turn head
□ Control in 90 prone position
□ Hands open □ Vocalize, coos
□Opens mouth expectantly
4 month
□Holds Head □Turn to noise & voice

5 month
□Roll over □ Grasps, transfer object
6 month
□sit w/ support □no head lag
□Babbles □Finger feeds
□Imitates action
7 month
□ Sit briefly w/ support
□Respond to name
8 month
□Sit alone w/o support
□Says Mama/Dada
9 month
□Pulls to stand, holds on
□pincer grasp □Respond to NO
□Peek a boo □object permanence
10 month
□Pulls self to stand □1st word
11 month
□Walk holding on
□follow 1 step command w/ gesture
12 month
□Stand independently
□ 1 step command w/o gesture
□2nd word □Drink in cup
□hold spoon □Comes by name
15 month
□Walk alone □imitate scribble
□Point -1 body part □3 cubes tower
18 month
□Scribble spontaneously
□2 body parts
2 y/o
□Climbs up & down
□makes strokes □2 word phrases
□2 step commands w/o gestures
□Cooperate in dressing
□tower 7 cubes
3 y/o
□Rides tricycle □Copy + & O
□ 3 word phrases □ give age, name
□Dry by night □use fork
□Put on shirt & shorts
□ 10 tower cubes
4 y/o
□Hop on foot □Catch ball
□Copy ∆ □Know 4 colors
□Brush, button & zip w/ assistance
5 y/o
□ Copy □ □Tie shoelace

6 y/o
□backward heel-toe walk
□Copy ◊ □3 step commands
□Teeth eruptions
7-19 y/o
□ School Adjustment I For Females:
□School Performance: I Ask about menstruation
□Secondary Characteristics: I Menarche?
□School Problems: I # of pads per day?
□Peer groups: I Regular / Irregular
□Body Image: I Duration:
□Tobacco/alcohol Use: i
Can ask: First teeth eruption: ____ , Achieve bladder control: ____, 1
st
step: ___, others: ____
UERM MED 2014 A2

IMMUNIZATION HISTORY
Immunizations: EPI only?
Dates:
What vaccines not yet given?
Where was vaccine received?
Adverse reactions?
Any plan to get other vaccines such as, pneumococcal, MMR? ___________


PAST DISEASES (ILLNESS:ask duration, frequency and severity of illnesses, if confined- date of
confinement and length of stay; Injuries, surgery, transfusions)




FAMILY HISTORY
Father’s Side:
Grandfather: Grandmother: Siblings:

Mother’s Side:
Grandfather: Grandmother: Siblings:

Siblings:

(ask COD of deceased relatives)

SOCIAL/ ENVIRONMENTAL HISTORY
Type of house: No. of people residing:
Number of: (___-storey ___-bedroom house)
Rooms: Bathrooms:___ (type: flush? Pour-flush?)
Garbage Collection: What? Frequency?
Safety of area:
Population density:
Water Source: For food: Bath/others:
Electrical Source:
Access to:
 Hospital/ health center
 Market
 Church
 School
 Police
Any factories or source of environmental hazard?
Any river nearby?
Any smoker in the house?
Daily activities of child / typical day of patient:


Father’s Name: Age:
Educational Attainment: Occupation:
Salary:
Mother’s Name: Age:
Educational Attainment: Occupation:
Salary:
REVIEW OF SYSTEMS
GENERAL
DESCRIPTION
UERM MED 2014 A2
□ Difficulty sleeping □trauma ____ □Change in appetite □ Sudden weight LOSS / GAIN
□Change in energy levels □change in school performance □Weakness □Fever
HEAD
□Head injury □headache □Change in vision □hearing problems
□itchy/watery eyes/runny nose
SKIN
□Skin rash □Acne □Birthmarks □Edema □pruritus
RESPIRATORY
□Cough □Asthma □SOB □DOB □hemoptysis □wheezing
CARDIOVASCULAR
□Cyanosis □Chest pain □Palpitation
GASTROINTESTINAL
□Abdominal Pain □flatulence □Diarrhea □Constipation □melena □hematochezia
□vomiting □ Dysphagia □jaundice □Change in appetite
GENITOURINARY
□Menstrual problem □Nocturia □Dysuria □Hesitancy □Nocturnal enuresis
□hematuria□polyuria □pyuria □oliguria
HEMATOPOIETIC / ENDOCRINE
□easy bruising/ bleeding □difficulty with HOT / COLD environment □polydipsia
□polyuria □polyphagia
NEUROLOGIC
□seizure □Change in behavior □Movement difficulties □Tremors
□Abnormal sense of smell □Language problem □Learning problems □syncope
□loss of consciousness □irritable □abnormally sleepy □numbness

PHYSICAL EXAMINATION

VITAL SIGNS: T = (site) HR= RR= BP= Pain= /10

ANTHROPOMETRIC MEASUREMENT: Length/ Height= Weight= BMI=
HC= CC= AC=

GENERAL SURVEY
Level of Consciousness: □Conscious □Lethargic □Stupor □Obtunded □Comatose
General Appearance: □Normal □Sign of Distress □Anxious □Unkempt
Nutrition: □Well nourished □Marasmus □Kwashiorkor □obese □overweight □Cachexic
Emotional State: □Cooperative □Calm □Irritated □Worried □Restless □Tense

HEEENT
Configuration: □Normocephalic □Hydrocephalic □Anencephalic □Others________
□Masses (Location:_____) □Craniosynostoses
Fontanelles: □Closed □Open _______ □Sunken □Bulging
Hair: □Fine □Coarse □Dry □Normal distribution
Scalp: □Clean □Dandruff □Lice □Lesion
EYES
Lids: □Symmetrical □ Edema/Swelling R L □ Ptosis R L
Periorbital region: □ Edema □ Sunken □ Discoloration
Conjunctiva: □ Pinkish □ Pale □ Lesion □Discharge
Sclera: □ Anicteric □ Subicteric □Icteric □Hemorrhages
Cornea & Lens: □ Smooth □ Clear □ Lesions □ Opacity □Arcus Senilis
Pupil Size: □ Equal □ Unequal R=_____mm L=_____mm
Reaction to light: R □ Brisk □ Sluggish □ Fixed
L □ Brisk □ Sluggish □ Fixed
Reaction to accommodation: □ Uniform □ Unequal
Convergence: □ Uniform □ Unequal
EARS
UERM MED 2014 A2
External Pinna: □ Normoset □ Symmetrical □ Tenderness
□ Gross abnormalities: ________________________________
External Canal: □ Impacted cerumen □ Discharge: □ Foul smelling
□ Serous □ Purulent □ Mucoid
Gross Hearing: □ Symmetrical □ Deafness R L
NOSE
Nasolabial Fold: □ Symmetrical □ Shallow R L
Septum: □ Midline □ Deviated □ Perforated
Mucosa: □ Pinkish □ Pale □ Reddish
□ Discharge: □ serous □Purulent □ Mucoid □ Bloody
Patency: □ Both Patent □ Obstructed R L □ Masses/Lesions: ________________________
Gross Smell: □ Symmetrical □ Olfactory Deficiency R L
Sinuses: □ Non-tender □ Tender: _________________
MOUTH
Lips: □ Pallor □ Cyanosis □ Dryness/Cracks □ Lesions
Tongue: □ Midline □ Deviation R L □ Atrophy
□ Fasciculation □ Lesions
Teeth: □ Complete □ Missing __________________________________
□ Caries □ Dentures □ Braces/Retainers
Gums: □ Pinkish □ Pale □ Bleeding □ Tenderness
Mucosa: □ Pinkish □ Pale □ Cyanotic
Speech: □ intact □ Slurred □ Aphasic □ others: ______________________________
Uvula: □Midline □ Deviation to R L
Mucosa: □ Pinkish □ Pale □ Reddish
Tonsils: □ Not inflamed □ Inflamed □ Exudates
NECK
Trachea: □ Midline □ Deviation to R L
Lymph nodes: □ Nonpalpable □ Palpable/enlarged □ Tender
Thyroids: □ Nonpalpable □ Enlarged
Others: □ Normal ROM □ Neck Rigidity □Brudzinski Sign

CHEST
Breathing Pattern: □Effortless □Hyperpnea □Tachypnea □Dyspnea □Use accessory muscle
Chest Expansion: □Symmetrical □Lag (RIGHT or LEFT) □Chest indrawing
Tactile Fremitus: □Symmetrical □DEC / INC = LEFT / RIGHT
Percussion: □Resonant □Dull □Hyperresonant
Breath Sound: ______________
Pericordal area: □Flat □Bulging □Heave □Thrill
PMI located at: _______
Heart Sound:
For Female: TANNER STAGE BREAST
1- Prepubertal, elevation of papilla only
2- Breast bud, elevation of breast &
papilla, areolar enlargement
3- Further breast and areolar enlargement,
no contour separation
4- Areola secondary mound
5- Mature
ABDOMEN
Skin: □Scars ______ □rash □lesions
Umbilicus: □Sunken □Bulging □Hernia
Contour: □Flat □Globular □Protuberant □Symmetrical □Mass at __________
Bowel Sound: □Absent □Hypoactive □Normoactive □Hyperactive
Bruit: □Present:_______ □Absent
Percussion: □Tympanitic □Dull □Resonant
Palpation: □Tenderness (Rebound or Direct)
Liver: Spleen:
UERM MED 2014 A2
Kidney: Bladder:
GENITOURINARY
MALE FEMALE
TANNER STAGE:
1. Prepuberal, no true pubic hair, childhood size
penis
2. Sparse, sl. Curled downy hair, enlargement of
testes, scrotum, scrotal skin reddens
3. Hair course, curled, darker, penile lengthen,
further growth
4. Adult hair, none in medial thigh, penile
enlargement, scrotal skin darkens
5. Triangle hair distribution, and adult genitalia
Penis: □discharge □tenderness □lesion
□nodular growth
Urethral Meatus: □Normal □hypospadia
□epispadia
Scrotum: □Equal □Tenderness
□enlargement (Right / Left) □Undescended
(Right / Left)
TANNER STAGE:
1. Prepubertal. No true pubic hair
2. Sparse growth sl. Pigment, downy hair, sl. Curl
along labia
3. Increase in hair, courser, curled, darker
4. Adult-type hair, none to thigh
5. Adult spread to thigh
Labia: □Symmetrical □Asymmetrical
□Pinkish □discoloration □edema
Vaginal discharge: □None □Bloody □foul
smelling □Whitish □greenish
Others: ______

EXTREMITIES
Peripheral pulse: □symmetrical □regular □warm □absent □faint □weak □strong
□bounding
Nail: □pink □pale □cyanotic □clubbing □capillary refill (___s)
Joints: □Redness □Warmth □crepitation □limited ROM □stiff □contracture
Legs: □Varus □Valgus
Gluteal Folds: □Symmetrical □Asymmetrical
Muscle tone

NEUROLOGIC
CN 1
CN 2
CN 3
CN 4
CN 5
CN 6
CN 7
CN 8
CN 9
CN 10
CN 11
CN 12
Cerebellar:
□fingers to nose □Romberg □rapid hand alternation □tandem walk □stand on one foot
Reflexes:
Infant
Suck Grasp (palmer/plantar) Pacing Cross extension
Root Tonic neck Stepping Glabellar tap
Moro Galant Rotation Palmar-mentum
Child (Hypo, Normo, Hyper)
Biceps:
Triceps:
Brachioradialis:
Patellar:
Achilles:
Cremasteric: