IDENTIFICATION DATA-

 Name of the Child –

 Age/Sex –
 Ward / Bed No.-
 Admission No.-
 OPD No.-
 Date of admission/ Time –
 Address –
 Educational Level of child –
 Religion –
 Father / Mother Name-
 Parent’s education-
 Parent’s Occupation –
 Family Income –
 Diagnosis –
 Consent doctor –

 CHIEF COMPLAINS –

 PRESENT MEDICAL HISTORY –

 PAST MEDICAL HISTORY –

 PAST SURGICAL HISTORY –

 SOCIO ECONOMIC STATUS (HISTORY) –

 PERSONAL HISTORY –

 FAMILY HISTORY OF ANY ILLNESS –

S. Name of the family members Relationship Age/Sex Health Status

No.
1.
2.
3.
4

 FAMILY TREE-

 BIRTH HISTORY-
 Antenatal History –
  Natal History –

 Immediate Post Natal History –

 FEEDING HISTORY –

 IMMUNIZATION STATUS –

 FUNCTIONAL HEALTH PATTERNS-

 Hygiene –

 Dietetic History –

 Activity exercise –

 Sleep & Rest –

 Cognitive / Perceptual –

 Coping stress tolerance –

  Values & Beliefs –

 PHYSICAL EXAMINATION-
 General Appearance –

 Physical assessment (Anthropometry)-

 Height –
 Weight –
 Mid arm circumference –
 Head circumference –
 Chest circumference –

 Vital Signs-
Temperature -
Pulse -
Respiration –
Blood Pressure –
Heart rate-

 Head –

 Eyes –

 Ears –

 Nose –

 Oral Cavity –

 Neck –
  Chest & Respiratory System –

 Abdomen & Inguinal Areas –

 Upper & Lower Extremities –

 Nervous System –

 Genital & Rectal Examination –

 Skin –

 SYSTEMIC EXAMINATION-

 MILESTONES / GROWTH & DEVELOPMENT-

 Physical and Biological Development –
Weight-

Height-

 Vital Signs-
  Temperature –
 Pulse -
 Respiration –
 Blood Pressure -
 Gross motor development-

 Fine motor development-

 Social /cognitive milestone-

 Language milestone-

 Play-

 INVESTIGATION-

S.no Investigation Patient Value Normal Value Remarks

1
2
3

4
5

6
7

 URINE ROUTEINE MICROSCOPY-

S.no. Parameters Pt.’s value Normal value

1
2
3
4
5
 OTHER INVESTIGATIONS-