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, REPUBIJC OF niE PHlUPPINES

PROVINCE OF BU~KIDNON
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Pediatric History and Physical Examination

Genera) Data:

Last name:
--------- Given Name:
·------ Age:_ Hospital#:. _ _ __
Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _- - : - - - - - - - - - - - - - - - - - -
Date of Birth:
Informant:
------Gender:------
Relation to Child:_ _ _ _ _ _ _ _ _ _ _ _ __
--------- i
!
Otlef ~plaint: _ _ _ _ __
History of Present mness:

famlty History:
Health of- Mother: · Father:._ _ _ _ other Siblings: _ _ _ _ _ __
Heredofamilial Diseases: Seizure( ), Alle~ies( ), Asthma( ), OM( ), Bleeding disorder( ),
Cancer{ ), Diabetes { } · ·
Social Condition/ History:
Occupation of Father:_ _ __, Mother · Child rank:. _ _ _ _ of Sllings_ __
#.

Educattonal Atteinment of Father:._ _ __, M<rther; Curen_t grade of px: _ ___,

Personal History
I. Prenatal and Birth History
Parity of Mother_ _ _ Age of Mother_ _ _Type of Delivery ( )NSD ( )CS secondary to _ __
{) Term ( )Preterm; Place of delivery ( ) Hospital ( ) LHC ();Home Birth Attendant ( )MD'
( )MW, ( )Hllot; Birth weight: _ _ Compllcatlons at Birth:.__·_ _ _ _ __

11. Feeding History

( )Breastfeeding, duration._ _ _~· ( )Milk formula, Name of MF _ _ __, dilution_ __
Age Solid Foods Introduced: Vitamin Supplement: _ _-,--_ _ _ _ _ __

Ill. Developmental History(mention month or ye ar when the ff wer~ performed)

Up to 1 y•r- smiled_____, Held head_ __, Rolled Over_ _ _ _ sat with support._ __
Crawled_ ___,Spoke single word _ ___, Sto.od w/ support._ _ First tooth._ __
From lto 3 Yell'J-walked w/ support~ walked alone_ _ _ Handedness._ _ __ Used
sentences._ _ ___,Tollettralned._ . _ __
4to 12years
School performance - poor( ),average( ), Excellent( ).
LMP/ Menarche (for adolescent females), _ _ _ _ _ _ Orcumclslo .__ _ _ _ __
IV. Immunization History llndicate no. of Doses)
BCG_ _ Hepa B . DPT_ __ _· OPV/IPV_ _ _HIB._ _ _ Measles_ __
MMR_ _ PCI/_
. _Typhold._ _ _ Hepa A Varlcella _ _ _ Others_ _ __

V. Past lllnessesllndude dates and complications)

Allergies.~_ __, Childhood Diseases: B..Asthma~_ __, chicken pox_ __, Measles_ _
Mumps._ _ __, Tonsllltis_ _ ___, RF Operations._ _ _ __
Others._ _ _ __

Physical Examination on Admission:

Yitai Signs: Temp:_ _HR:_RR:___,BP:_ __ Wt:. _ _ _ Ht:,_ _ _ __
General
Survey!._ _ _ _ _ _ _ _....;..._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
S~n:._ _ _ _ _ _ _ _ _ _ _ _ _ _.....:._..:.__ _ _ _ _ _ _ _ _ _ _ _ _ __
HEENT::_ _ _ _ _ _ _ _ _ _ _ _ _ _ _Neck:._ _ _ _ _ _ _ _ _ _ _ _ __
0.estand l.ungs:._ _ _ _ _ _ _ _CVS:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Abdomen:_ _ _ _ _ _ _ _ _ _ _ back a,:,d Spine_·- ' - - - - - - - - - - - -
Genitals: Extremities:_ _ _ _ _ _ _ __
Neurologif·------·
Deep Tendon Reflex: _ _ _ _ __ Motor Strength:._ _ _ _ _ __
Cranial Nerves:
I VII
II VIII
Ill IX i
IV X ,
V XI
VI XII
Review of Systems:
~ I : ( )Weight loss, ( )Body malaise, ( )Heada~e, ( )Behavioural Changes
Skin: ( )Rashes, ( }Bruising, ( )Lumps, ( )Bleeding, ( )Hair Changes
Eyes: ( )eye pain, ( )Visual problems, ( )drscharges, ( )$welling ·
Ears: ( )Pain, ( )discharges, ( )Swelling, ( )hearing protilem
Mouth and Th~oat: ( )dental carries, ().Tooth ache, ( )dysphagla, ( )pharlngltls
Chest and Lungs: { )difficulty of breathing, ( )ch~t pains, ( )Nocturnal Cough
CVS: ( )Orthopnea, ( )Palptations,( )Cyanosls
GIT: ( )abd. Pain, ( )vomiting, ( ) Loose bowel movement, ( ) constipation, ( ) Jaundice
GUT: { )Discharge,,( )dysur1a,( )hematurfa, ( )polyurla
Extremities: ( ) difficulty In walking, ( )numbness·
Admittlne lmpreision::_ _ _ _ _ _~ - - - - - - - - - : : - : - - - - - : - - -
Admittin1 Physidan:.--,.------------ -~-Date:_ __:.,_ __