CLINICS: Pediatrics

History

I. General Data
A. Name
B. Age
C. Sex
D. Race
E. Birthplace
F. Religion
G. Address
H. Informant and Reliability
II. Chief Complaint
III. History of Present Illness
A. Onset
B. Intensity of symptoms
C. Location
D. Quality
E. Duration
F. Severity – pain score
G. Frequency
H. Factors aggravating/relieving
I. Medications

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 1. Generic and brand names
2. Actual dose
3. Duration of treatment
4. Compliance
5. Associated symptoms
IV. Personal History
Gestational, birth and neonatal histories should be included only in
patients <2y.o and if related to the illness for children >2y.o
A. Gestational History
1. Age of mother during pregnancy
2. Parity
3. Infections/ diseases during the span of pregnancy
4. Medications taken during pregnancy
5. Radiation exposure
6. Duration of gestation
B. Birth
1. Term or premature or post mature
2. Manner of delivery
3. Person who attended
4. Birth weight
C. Neonatal History
1. APGAR Score
2. Congenital birth injury
3. Respiratory or feeding difficulties
D. Feeding history

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 1. Infancy (<2y.o)
a. Type of feeding
i. Exclusive or mixed
ii. Frequency
iii. Formula used, dilution and amount per day
b. Complementary foods
i. Age introduced
ii. Foods initially and subsequently introduced
iii. Frequency of feeding
2. Childhood and Adolscents (2-20years)
a. Appetite
b. Usual food intake and amount per day
E. Development/ Behavior History
1. Young children (1-5yrs)
2. Middle childhood (6-11yrs)
3. Adolescence (10-20yrs)- HEADS/S/FIRST
a. Home
b. Education/ School
c. Abuse
d. Drugs
e. Safety
f. Sexuality/ Sexual Identity
g. Family/ Friends
h. Image
i. Recreation

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 j. Spirituality & Connectedness
k. Threats & violence
l. For female: Menstrual history and self-breast
examination
F. Past Illnesses (MMASH)
1. Contagious illnesses
2. Other medical illnesses: hospitalizations
3. Operations
4. Allergies
V. Immunization History
VI. Family History
VII. Socioeconomic History
VIII. Environmental History (Include places visited)

Physical Examination

I. General Survey
A. Mental state or sensorium
B. Presence of cardiopulmonary distress
C. Color
D. Ambulatory or bedridden
E. Nutritional state
F. State of hydration
II. Vital signs

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 A. Temp
B. Heart rate
C. Respiratory rate
D. Blood pressure (if >3y.o)
E. Oxygen saturation
III. Anthropometric Data
A. Weight
B. Length (for <2y.o) or Height (for >/= 2y.o)
C. Head circumference ( for <3 y.o)
D. Special measurements
1. Chest circumference
2. Abdominal circumference
3. Arm span & U/L ratio for growth disorders
IV. Skin
V. Head, Eyes, Ears, Nose, Throat
VI. Neck
VII. Chest and Lungs
VIII. Heart and Vascular System
IX. Abdomen
X. Kidneys
XI. Genitalia
XII. Anus and Rectum
XIII. Extremities

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