Done by \ Rashad Alhaidhani

History model in pediatrics course

• Personal data:
1. Name:..............................................................................................................................

2. Age:........................................... 3. Birth order:........................................ 4. Sex:......................

5. Residence:......................................... 6. Place of birth:.........................................
7. Informer:........................................ 8. Date of admission:........................................

9. Date of history taking:............................................................................

10. Time of start:......................................... 11. Time of end:.........................................

• Chief complaint:
.................................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

History of present illness:

Healthy last time: ..................................................................................................................................

Analysis each symptom:

• Onset: ..............................................................................................................................................

• Course: ............................................................................................................................................

• Duration: ...........................................................................................................................................

• Natural: ............................................................................................................................................

• aggravated factors: .....................................................................................................................

• Reliving factors: .............................................................................................................................

• Associated symptoms & characters of them: ..........................................................................

............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
............................................................................................................................................................................

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Done by \ Rashad Alhaidhani

• Review of other systems:

CNS (fits, syncope, tinnitus, blurring vision, headache, dizziness, convulsion, etc..)
....................................................................................................................................................................................

....................................................................................................................................................................................

CVS (chest pain, palpitations, dyspnea, cyanosis, limb swelling, edema, syncope, etc..)
....................................................................................................................................................................................

...................................................................................................................................................................................

Respiratory (cough, wheezing, sore throat, chest pain, dyspnea, orthopnea, earache,
hemoptysis, history of aspiration, cyanosis, etc..)
....................................................................................................................................................................................

....................................................................................................................................................................................

GIT ( abdominal pain, dysphagia, hurt burn, abdominal distention, nausea, vomiting,
diarrhea, hematemesis, constipation, Melanie, haematochezia (rectal bleeding),
allergy to food “gluten - egg - peanut - lactose “ etc..)........................................................
...................................................................................................................................................................................

....................................................................................................................................................................................

Urinary system (loin pain - groin pain - suprapubic pain, dysuria, strangury, frequency,
urgency, polyuria, oliguria, nocturia, anuria, hematuria, dripping of urine, etc..)
....................................................................................................................................................................................

....................................................................................................................................................................................

Musculoskeletal system (arthralgia, bone pain, myalgia, stiffness, redness & warmth of
joint , swelling, weakness, deformity, etc..)
....................................................................................................................................................................................

....................................................................................................................................................................................

Endocrine (heat intolerance, cold intolerance, increase or decrease the weight,

polydipsia, polyuria, polyphagia, pain of thyroid, etc..)
....................................................................................................................................................................................

....................................................................................................................................................................................

Hematological (easy fatiguability, petechia, epistaxis, Melanie, ecchymosis, skin rash,

etc..).......................................................................................................................................................................
.................................................................................................................................................................................................

.......................................................................................................................................................................................

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Done by \ Rashad Alhaidhani

• Past history
1. Similar condition:..................................................................................................................................

2. Previous medical problem:...............................................................................................................

a. Infectious

-focal (CNS - Chest - GIT - ........................................................ )

-Exanthema (measles- scalrt fever - chicken pox -............................................)

b. Other illnesses (accidents - trauma - allergy -............................................ )

c. Admitted to hospital or not & ask when & why? (Surgical or anything else)
............................................................................................................................................................................................

............................................................................................................................................................................................

• Perinatal history
Antenatal history *during pregnancy*

1. Age of mother during pregnancy:........................................................................................................

2. Disease during pregnancy:.................................................................................................................
3. Maternal medication:...............................................................................................................................

4. Maternal infection:...............................................................................................................................
5. Exposure to radiation or UTs:...............................................................................................................
6. Maternal smoking:...............................................................................................................................

7. Qat chewing:..............................................................................................................................................
8. Blood group:....................................................................................................................................................
9. Mother nutrition:........................................................................................................................................
10. Mother Vaccination:.....................................................................................................................................

11. Regular antenatal care:.........................................................................................................................

Natal history

1. Time of delivery (at term or premature): .........................................................

2. Place of child birth:..................................................................................................................

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Done by \ Rashad Alhaidhani

3. Mode of delivery:
a. Normal home delivery. c. Abnormal difficult home delivery

b. Normal vaginal hospital delivery. d. Abnormal cesarean hospital delivery

4. Duration of delivery:..................................................................................................................
5. Use of anesthesia or analgesia:.........................................................

6. Delivery conducted by who:.....................................................

Postnatal

1. Onset of crying:.............................................................................................................................................

2. Need of resuscitation:...............................................................................................................................
3. Abnormal discoloration:..........................................................................................................................
4. Birth weight:.............................................................................................................................................

5. Breathing difficulties:...................................................................................................................................
6. Incubator care:...........................................................................................................................................
7. Neonatal history of:

A. fever B. Convulsion C. Jaundice D. Rash.

E. Vomiting. F. Bleeding. G. Congenital anomalies
.....................................................................................................................................................................................

• Feeding history
1. Onset of feeding:.........................................................
2. Type of feeding (breast - bottle - mixed):.........................................................
3. Quantity:......................................................... 4. Frequency:.........................................................

5. State of appetite:.................................. 6. Supplement (vitamins - iron):...............................

7. Introduction of complementary diet (normally at the 4th month)
Ask about : (time of onset - type and nature of food).........................................................

8. Weaning :( when - type of weaning food - any problem with weaning)..............................

......................................................................................................................................................................................

9. Exposure to sunlight:.........................................................

10. Any problem of feeding as refusal, regurgitation, etc... .........................................................

........................................................................................................................................................................................

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Done by \ Rashad Alhaidhani

• Developmental history:
A. Infancy: ask is infant does these thing & when?

1. Fix to light :.............................................................................................................................................

2. 1st social contact (smile) :........................................................................................................................

3. Head support:.............................................................................................................................................
4. Recognize his mother:...........................................................................................................................
5. Sitting (supported -unsupported):................................................................................................

6. Crawling:.............................................................................................................................................
7. Standing (supported -unsupported):................................................................................................
8. Walking (supported -unsupported):..................................................................................................

9. Spoken word:........................................................................................................................................
10. Dental eruption:........................................................................................................................................

B. Early childhood:

1. Ability to use cup or spoon:.................................................................................................................

2. Ascend and descend stairs:...............................................................................................................

3. Bowel and bladder control:...............................................................................................................
4. Speech development:...............................................................................................................

C. School childhood (late childhood):

1. School performance:..........................................................................................................
2. Learning ability:..........................................................................................................
3. Sexual development:..........................................................................................................

4. Social contact at school:..........................................................................................................

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Done by \ Rashad Alhaidhani

Vaccination history (complete - incomplete - non vaccinated)

BCG Polio vaccine MMR DPT Penavalent Pneumococcal Rota Other

complication: .............................................................................................................................................

• Family history
1. Parent age :F M

2. Consanguinity of parent : ........................................................................................................

3. Parent health :.............................................................................................................

4. Siblings (age - number - health - (stillbirth - miscarriage) )

.......................................................................................................................................................................................
............................................................................................................................................................................................
...........................................................................................................................

5. Similar condition in family:........................................................

6. Any familial diseases:........................................................

7. Family death cause:........................................................

• Socioeconomic history
1. Parents works:.............................................................................................................................................

2. Education level:......................................................................................................................

3. Income/month:...........................................................................................................

4. No. of room / No. of family members:..............................................................................

5. The water supply:....................................................................................................................................

6. Drainage system (toilet) :..................................................................................................................

7. Animal contact :..................................................................................................................