Informant Relationship to Pt: Reliability

GENERAL DATA:
Name: Age: Birthday:
Gender: Residence:
Civil Status: Religion: Ethnicity

B. CHIEF COMPLAINT: Enlist Meds of mother during gestation:

Gestational age at delivery:

C. HISTORY OF PRESENT ILLNESS
Amplifies the chief complaint Birth history
Description of the symptoms developed Length of labor
Site Fetal distress
Onset Type of delivery CS
Character Vaginal
Radiation Use of forceps
Associated signs & Anesthesia
symptoms Breech delivery
Timing (duration &
frequency) Neonatal Period
Exacerbating APGAR Score:
Factors Breathing problems:
Relieving Factors Need for ICU:
Severity Hyperbilirubinemia:
Birth injuries:
Pertinent positives and negatives Feeding problems:
Length of stay:
Medications Birth weight:
FEEDING
Type Time Period
Allergies Breast feeding
Formula Feeding ***
Complimentary Feeding
D. PAST PERSONAL HISTORY (< 2 detailed) Appetite and Food eaten: (2-20 y/o) _______________________
____________________________________________________
Gestational History
E. DEVELOPMENTAL & BEHAVIORAL HISTORY
Mothers GPTPAL score:
Home
Bleeding Infectious illness Education
Trauma Medications Activities
HTN Drugs Drugs
Fever Alcohol Suicidal
Smoking Membrane rupture Tendencies
 Measles
Menstrual history: Rubella
Regular or irregular Mumps
Every how many days Influenza
LMP Varicella
Pads consumed Hepatitis B
Pneumococci
Developmental milestones Herpes zoster

Hospitalizations Date

Date Indication Type of Surgery

---- Additional information for adolescent patients

G. FAMILY HISTORY
SPECIFIC DISEASES
____ HTN ____ CAD ____ DM
____ Hypercholesterolemia ____ Stroke
____ Thyroid diseases ____ Renal disease
____ Arthritis ____ Tuberculosis ____ Asthma
____ Lung Disease____ Seizure disorder
____ Mental illness____ Suicide
____ Substance abuse ____ Allergies
____ Cancers/Malignancies

H. PERSONAL AND SOCIAL HISTORY

Educational level: Family origin:
F. PAST MEDICAL HISTORY Current household: Personal interest:
Exercise/physical activity
Childhood Illnesses Diet:
____ Measles ____ Rubella ____ Whooping cough ____ Supplements:
____ Chicken pox ____ Rheumatic fever ____ Meat ____ Fish ____ Fruits and vegetables
____ Scarlet fever ____ Polio ____ Caffeinated drinks Dietary restrictions:
Vices:
Immunizations ____ Smoking ____ Alcohol beverage drinking
Vacinne Date Given Type: # Of glasses:
Tetanus ____ Substance abuse
Pertussis Sources of Stress:
Diphtheria Leisure Activities:
Polio Alternative healthcare practices: