PEDIATRIC MEDICAL HISTORY
Date & Time: __________________
Source of History: __________________
GENERAL DATA
Name: _______________________________________
Age: _____ Sex: _____ Religion: ______________
Address: ______________________________________
Nationality: ____________________________________
Date of Birth: __________________________________
Place of Birth: _________________________________
# of Adm.: _____ Date of Adm.: __________________
Place of Adm.: _________________________________
CHIEF COMPLAINT _______________________________
HISTORY OF PRESENT ILLNESS
Onset: _____________________________________
Duration: __________________________________
Nature and Character: ________________________
Severity: ___________________________________
Aggravating factor(s): ________________________
Relieving factor(s): ___________________________
Associated s/sx: _____________________________
Treatment: _________________________________
__________________________________________
Effect of problems on feeding and sleeping: _______
__________________________________________
Medications:
(Name) _________________________________
(Dosage) ________________________________
(Response) ______________________________
PRENATAL HISTORY
Mother’s Age during pregnancy: ________________
OB Score during pregnancy: G( ) P ( ) F( ) P( ) A( ) L( )
Prenatal Care and Visits (when, where, attended by, and with
who): ____________________________________
________________________________________
Labs taken: ______________________________
Illnesses during pregnancy (include the time): _______
_______________________________________
Drugs taken during pregnancy: ________________
________________________________________
Smoking: ___________ Alcohol intake: _________
Reliability: _____
NATAL HISTORY
Age of Gestation: ________________________________
Birth Rank: ________ Birth Weight: _________________
Mode of delivery: ________________________________
Place of delivery: ________________________________
Attending Physician: ______________________________
Condition upon delivery (APGAR score): ______________
______________________________________________
Perinatal complications: ___________________________
______________________________________________
Duration of stay in hospital/nursery: __________________
POSTNATAL HISTORY
Feeding history:
(Type of feeding) ______________________________
(Age when semisolids / solids introduced) __________
___________________________________________
Growth and Development (approximate age when major
developmental milestones are acquired): ______________________
______________________________________________
______________________________________________
______________________________________________
Educational Attainment: ___________________________
Immunization history (include age when received):
BCG ( )_____ Hep B ( )_____
DPT ( )_____ OPV ( )_____
HIB ( )_____ AMV ( )_____
PAST MEDICAL HISTORY
Past illnesses and hospitalizations (dx/problem and treatment): _______
___________________________________________________
Allergies (food, drug, materials): _______________________________
FAMILY MEDICAL HISTORY
Present state of parents: _______________________________
___________________________________________________
Present state of siblings: _______________________________
___________________________________________________
Heredofamilial diseases (DM, HPN, Heart problems, TB, Cancer, Arthritis,
Asthma, Allergies, Anemia, Stroke, Kidney problems): ____________________
___________________________________________________
PERSONAL SOCIAL HISTORY
Parent’s age and their work: ____________________________
___________________________________________________
Describe their dwelling place briefly: _____________________
__________________________________________________