ST. ANTHONY COLLEGE OF ROXAS CITY, INC.

San Roque Extension, Roxas City, Capiz, Philippines 5800

Member, DC-SLMES Philippines
Empowering Communities, Building Futures
+
COLLEGE OF NURSING
SY 2020-2021

HEALTH ASSESSMENT FOR CHILDREN AND ADOLESCENTS

Biographic Data

1. Child’s Name: ________________________________________________

Nickname: _____________________________________
Parents’/Caregivers Name: _______________________________________________
_______________________________________________
_______________________________________________
2. The child’s primary health provider: ___________________________________________
The child’s last well-child care appointment: _______________________________
3. Address: _________________________________________________________________
4. Do the parents and child live in the same residence? YES ___ NO ___
Are the child’s parents:
Married? ___
Single? ___
Divorced? ___
Homosexual? ___
Who else she lives in the residence? __________________________________________
Parents’ Ages: Mother: ________________
Father: ________________
5. Child’s age: _____________
Date of Birth: ___________________

6. Is the child adopted? ___ foster? ___ natural? ___

7. Ethnic origin: ____________________________________
Religion: _______________________________________
8. Parents’ Occupation: ______________________________
______________________________

History of Present Health Concern

1. Describe the child’s general state of health.

______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
Does the child have chronic illness? YES ___ NO ___
2. Does the child have any allergies? YES ___ NO ___ If yes, what is the specific allergen?
____________________ How does the child react to it?
______________________________________________________________________________
3. What prescriptions, over-the-counter medications, devices and treatments and home or folk
remedies is the child taking?
 Name of the Drug Dosage Frequency Reason it is Administered

Past Health History

1. Where was the child born? _________________________________________

2. Type of delivery: _________________________________________________
Any problems during the delivery? YES ___ NO ___
Vaginal infections at time of delivery? YES ___ NO ___
3. The child’s APGAR score: _________________________________________
4. Weight: ________________
Length: ________________
Head circumference: ___________________
Any problems after birth? YES ___ NO ___ If yes, specify: __________________________
5. Past illness or injuries: _____________________________________________________
Has the child ever been hospitalized? YES ___ NO ___
Has the child ever had any major illness? YES ___ NO ___
Has the child ever experienced any major injuries? YES ___ NO ___
6. Immunizations the child received this far:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Any reactions to immunizations? YES ___ NO ___
7. Do certain diseases/conditions run in the family? YES ___ NO ___
8. Does the child have family members with communicable diseases? YES ___ NO ___
 REVIEW OF SYSTEMS

GUIDE QUESTIONS

Skin, Hair, Nails

 Has your child had any changes in hair texture?
 Does your child complain of scalp itching?
 Have you noticed any changes in your child’s nails? Color? Cracking?
Shape? Lines?
 Has your child been exposed to any contagious disease such as measles,
chickenpox, lice, ringworm, scabies and the like?
 Has your child ever had any rashes or sores? Acne?
 Has your child had any excessive bruising or burns?
 Does your child use any cosmetics? Have tattoos? Have any pierced body
parts?
 Does your child have any birthmarks?

Head and Neck

 Has your child ever had a head injury?
 Does your child experience headaches? How frequently?
 Has your child ever had swollen neck glands for any significant length of
time?
 Has your child ever experienced any neck stiffness?

Eyes and Vision

 Does your child excessively cross eyes?
 Does your child frequently rub his or her eyes or blink repeatedly?
 Does your child strain/squint to see distant objects?
 Has your child’s vision been tested?
 Does your child wear glasses or contact lenses? Does he/she wear them
 when needed? Do the glasses help your child to see better?

Ears and Hearing

 Does your child appear to be paying attention when you speak?
 Does your child speak? At what age did talking start?
 Does your child or adolescent listen to loud music?
 Does your child use a hearing aid? If so, has it improved the child’s ability to
interact and understand others?
 Has your child had frequent ear infections? Tubes in ears?
 How frequently does your child have his or her hearing tested?

Mouth, Throat, Nose and Sinuses

 Has your child ever had any difficulty swallowing or chewing?
 Has your child ever had strep throat, tonsillitis or any other mouth or throat
infections? Does your child get frequent oral lesions?
 When did your child’s teeth erupt? When did the child lose his/her baby
teeth? When did adult teeth erupt?
 Does your child have any dental problems? Does he visit the dentist
regularly? Does he wear any dental appliances?
 Does your child experience nosebleeds?
 Does your child have any sinus problems?

Thorax and Lungs

 Has your child ever had cough, wheezing, shortness of breath, nocturnal
dyspnea? If so, when does it occur?
 Has your child received the influenza vaccine?
 Does your child smoke? When did the child start smoking? How much does
he smoke?
 Is your child exposed to second-hand smoke?
Breast and Lymphatics
 Has your daughter started developing breasts (thelarche)? If so, when did
development start?
 Have you noticed any abnormal breast development in your son or young
daughter?

Heart and Neck Vessels

 Has your child ever experienced chest pain, heart murmurs, congenital
heart disease or hypertension?
 Has your child ever complained of fatigue? Does your child have difficulty
keeping up with peers when running or exercising?
 Has your child ever fainted?
 Has your child ever turned “blue” during activity?
 Do you believe that your child is meeting the normal growth requirements
for his or her age?

Peripheral Vascular System

 Does your child ever experience bluing of the extremities? Do your child’s
hands and/or feet get unusually cold?
 Has your child ever had problems with blood clots?

Abdomen
 Has your child ever had any excessive vomiting? Abdominal pain? Please
describe.
 Does your child have any digestive problems (i.e. irritable bowel,
constipation)?
 Has your child ever experienced any trauma to the abdomen?
 Does your child have any hernias?

Genitalia and Sexuality

 How often does your child urinate? How many wet diapers do you change
 per day?
 At what age was your child toilet (bladder) trained?
 Does your child wet his or her pants?
 Is there any history of frequency, burning, pain during urination?
 Do you have any concerns about your child related to masturbation,
asking/answering questions about sex, not respecting other’s privacy or
wanting too much privacy?
 Has anyone ever touched your child in a way that made him or her feel
uncomfortable?
 Has child started puberty, thelarche, menarche?
 Has the child started having wet dreams (nocturnal emissions)?
 Do you know how to perform breast self examination or testicular self
examination?

Menstruation:

 How old were you when you started menstruating?

 When was your last menstrual period?
 What is your menstrual cycle schedule? Has it always been this way?
 What is your bleeding like? Light, moderate or heavy?
 Do you experience any cramps? Tell me about them...
 Do you experience any other physical or emotional discomfort associated
with menstruation?
 Do you use tampons/napkins? How frequently do you change them?

Sexual History

 What was your age at first intercourse?

 Have you received information regarding the Human Papillomavirus
vaccine that can reduce the incidence of cervical cancer? Have you
 received the vaccine?
 Have you ever had a pap smear? Do you experience any discomfort/pain
with intercourse?
 How many sexual partners do you have/have you had?
 What type of contraception do you use and how do you use it? Do you use
condoms? How do you use them?
 Have you ever had a sexually transmitted disease?
 Were you ever pregnant? What was the result of that pregnancy?
 Have you had or considered having a gynaecologic examination?

Anus and Rectum

 How often does your child have bowel movement? What does it look like?
 At what age was your child toilet (bowel) trained?
 Does your child ever soil his or her pants?
 Is there any history of bleeding, constipation, diarrhea, rectal itching or
hemorrhoids?

Musculoskeletal System
 Has your child ever had limited range of motion, joint pain, stiffness,
paralysis? Have you noticed any bone deformity?
 Has your child ever had any fractures?
 Has your child ever used any corrective devices (orthopedic shoes, scoliosis
brace)?
 Describe your child’s posture.
 Is your child involved in any sports? What type of protective gear do they
use?

Neurologic System
 Does your child have any learning disabilities? Does your child have any
attention problems at home or at school?
 Has your child ever experienced any problems with memory?
 Has your child ever had a seizure?
 Has your child ever had a head injury?
 Has your child ever experienced any problems with motor coordination?