Pediatrics

Hx case sheet

Patient’s name: Age & Date of birth:

Patient demographics

Gender: Address: Blood group:

Date of admission: Source of Hx:

Chief complaint(s):

Hx of Present illness:
System review :

General GIT
Feeding and appetite Vomiting
Irritability Abdominal pain
Weight loss Diarrhea
Cardiovascular Constipation
Breathlessness Jaundice
Sweating on feeding Genitourinary tract
Cyanosis Frequency
Respiratory Dysuria
Breathlessness Nocturia or enuresis
Runny nose Hematuria
Cough incontinence
Noisy breathing
Sore throat or earache
Hemoptysis
Neurological Infections
Irritability Skin rash
Drowsiness Contact with infectious patients
Fits or abnormal movements Recent travel
Headache Musculoskeletal
Weakness Joint swelling
Numbness or unpleasant sensation Joint pain
Hematological & oncological
Pallor
Jaundice
Bone pain
Bruises
Bleeding from nose

Past medical Hx:

Pregnancy & Neonatal Hx:

Pre-natal Hx:
Natal Hx:

Post-Natal Hx:

Nutritional Hx:

Immunization Hx:
Developmental Hx

Family & Social Hx: