SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART

Assumption Rd., Baguio City, Philippines

DEPARTMENT OF PEDIATRICS

GENERAL DATA D. FEEDING Hx

Name:_______________________________________ Sex:_______ Food preferences: _______________________________________
Age: _______ Birthday: _________Birth Place: _________________ ( ) Vitamins: _____________________________________________
Address: ________________________________________________ Meal ITEM and QUANTITY Kcal per day
Citizenship: ( ) Filipino ( ) Others: ____________________________ Breakfast
Religion: ( ) RC ( ) INC ( ) Born Again Others: ___________________ Lunch
Weight: _____________ kg Height: ____________ cm
Dinner
Date of Admission: ________________________ Time: _________
Informant:_________________________ Reliability: ____________ Snacks
TOTAL:
CHIEF COMPLAINT:_______________________________________ RENI:

E. GROWTH AND DEVT/BEHAVIORAL Hx

HISTORY OF PRESENT ILLNESS 1. Physical Growth
Sequence of events! Onset, Provocation/Palliation, Quality, Region/ BW Present Wt
Radiation, Severity, Time (Hx), Aggravating/Alleviating Fx, Associated BL Present Ht
Symptoms, Attributions/Adaptations Birth HC Wt-for-length
(At the back) Birth CC Length-for-age
BMI-for-age
HC-for-age
Acknowledge the patient for seeking consult. CC
AC
PAST PERSONAL HX Arm span
A. MATERNAL Hx & PRENATAL Hx “How was your pregnancy?” Lower segment
Age of the mother: _______ Age of father: __________ Upper segment
cognizant at _____________ AOG d/t ________________________ U/L ratio
Prenatal Check-up: total of PNCUs ______ BMI
First: AOG ______________________ by:________in ____________
Last: AOG ______________________ by:________in ____________ 2. Developmental Milestones. Pls refer on the table at the back.
UTZ: AOG: _____________Result:________ Quickening:__________
Maternal Illness:( )DM ( )HTN ( )asthma ( )epilepsy ( ) kidney prob PAST MEDICAL HX
( ) vaginal infxn ___________________How so?:________________ ( ) Previous Hospi:________________________Date:_____________
Outcome:________________________________________________
________________________________________________________ ( ) Surgical Proc: ________________________ Date:_____________
Labs done + Results:
________________________________________________________ ( ) Measles ( ) Chickenpox ( ) Mumps ( ) Asthma ( ) Seizure ( ) Blood
Prenatal Meds: ___________________________________________ If pre-term: ( ) Chronic Lund dse ( ) Nutritional prob ( ) Devt abn
Vaccines:________________________________________________ Allergies: ( ) Drug: __________________ ( ) Food:_______________
Wt gained: _______ Prev wt: _________ Post wt: ______________ How so? s/sx:_____________________________________________
*( ) smoker ( ) alcohol drinker ( ) illicit drug use: __________________ Maintenance Meds: _____________________________________

OB Score: G P ( - - - ) Parity: tot # of deliveries ≥ 24wks (6m) gestations IMMUNIZATION HX

Term deliveries: ≥ 37wks Pre-term deliveries: 20-36 6/7wks Abortions: <20wks ( ) Complications: ______________________________
Date Sex AOG Manner Place Complications ANTI-HELMINTHIC: Drug/Dosage: _____________ Date/Age: _____
VACCINE DOSE TYPE SITE AGE DATE
G1 BCG - At birth
G2 1(Mono) At birth
G3 2 10w
Hepa B
3 14w
Booster >1y
Pentavalent 1 6w
B. NATAL Hx (DTwP-Hib- Hep 2 10w
Delivered: _____ AOG via ( ) NSD/( ) CS by _________ in ________ B) 3 14w
Age of mother when delivered:________ Presentation: ___________ 1 6w
Duration of rupture to delivery ( <18o) _____________ BW: ____kg OPV 2 10w
3 + IPV 14w
1 6w
Abnormalities: ( ) meconium stained AF ( ) cord coil _______________ H. influenza B 2 10w
3 14w
APGAR (Appearance, Pulse, Grimace, Act, Respiration: 0-15): _______ 1 6w
Pneumococcal
( ) Vit K ( ) Vit A ( ) BCG ( ) NBS: Result:______________ 2 10w
conjugate (PCV)
Sent home after: _____ days 3 14w
1 >6w(4w)
Rotavirus
2 <32w
Influenza 1 q1y
C. POST/NEONATAL Hx Measles 1 9m
( ) Breastfeeding Onset: ___________ Qhrs:________Dur: ________ MMR 1 1y (3m)
Burp: ___________ Date Weaned (1yo):_________ Varicella 1 1y(3m)
( ) Formula milk: _______________ Dilution: _______ml Q _____ hrs 1y
Vitamins: ______ Started solid foods feeding: ____ mo ie__________ Hep A 1 2y
( ) diarrhea ( ) constiptation→cx: ________ ( ) Congenital deformities JE 1 9y
HPV 1,2 9y(0, 6m)
FAMILY HISTORY RR (nl:14-22)
Father: Age: _______Educ:_______________Work:______________ Temp (nl:36-37.80C)
Mother: Age:______ Educ:_______________Work:______________
Source of Income: _________________________________________ Skin ( ) fair ( ) cyanosis ( ) pallor ( ) jaundice
Siblings: #:_______ Age: ________ Stat:______________________ ( ) warm to touch ( ) good skin turgor Good capillary refill: _______sec
Nails: ( ) biting ( ) clubbing ( ) pitting
_______________ Age: ________ Stat: ______________________
Head: ( ) normocephalic. ( ) No asymmetry
( ) Similar illness in the family:_______________________________ Hair is ( ) black ( ) evenly distributed ( ) no lice infestation.
( ) PTB ( ) seizure ( ) bronchial asthma ( ) no palpable lumps, deformities, and tenderness on the scalp.
( ) hypertension ( ) cancer ( ) diabetes mellitus Eyes: ( ) in line with each other ( ) Non-sunken eyeballs. ( )pinkish conjunctiva
( ) heart disease ( ) kidney diseases ( ) birth defects ( ) clear bulbar conjunctiva ( )No excessive lacrimation
( ) arthritis Others: ________________ ( ) Pupils are equally round and reactive to light and accommodation.
( ) Intact papillary reflexes.
SOCIAL AND ENVIRONMENTAL HISTORY ( ) Extraocular movements normal.
Sleep. # of hours: ________ ( ) Nightmares Others: _____________ Ears: ( ) normally set in line with the lateral canthus of the eyes.
( ) No lesions, deformities and discharges noted.
( ) Tympanic membrane visible and intact
School: __________________________________ Grade: ________
( ) minimal cerumen.
( ) Delay _______ Keep-up? _______
Act/Subj:________________________ Problems:_________ ( ) Nose: ( ) septum is at the midline. ( ) Clear mucoid discharge,
Bully ( ) Mannerisms: _____________ ( ) Tantrums ( ) no alar flaring, deformities ( ) no bleeding noted.
Habits: ___________________________________________TV ( ) Turbinates not inflammed.
( ) No frontal and maxillary sinus tenderness noted.
Time:______ Intrxn w/ others:_______________________________
Mouth ( ) lips are pinkish and moist.
+ ( ) Buccal mucosa is also pinkish and moist, ( ) no lesions, or ulcers.
As a person: _______________Best:___________ Worries:_______ Phary ( ) No tongue deviations noted. ( ) uvula is at the midline.
nx
( ) No pharyngeal wall congestion. ( ) No tonsillar enlargement.
House: Envt: ( )Highway___________ ___ storey ( )concrete ( ) wood Dentition: UPPER:
Ventilation: _____________ No. of house members: ________ LOWER:
( ) Smoke ( ) Nearby Dumpsite ( ) Factories Neck: ( ) No masses and lesions on the neck.
Endemicity? : _________________ ( ) Trachea is at midline.
Drinking H2O: ____________________ If tap, boiled? ( ) Yes ( ) No ( ) Lymph nodes are non-palpable.
Domestic H2O: ____________________ If tap, boiled? ( ) Yes ( ) No Chest ( ) No visible mass or lesions ( ) no subcostal and substernal retractions.
Garbage Disposal: _______________ x/week and ( ) Symmetrical chest expansion ( ) equal TF ( ) No tenderness felt
Toilet #: ______ Type:______ Lungs ( ) Lungs are resonant. ( ) Clear breath sounds heard on both lung fields.
( ) not tachypneic ( ) no stridor, nor wheezing.
( ) History of travel: ___________________________ Date:________
Heart ( ) Adynamic precordium. ( ) Heart rate and rhythm are regular.
( ) S1 is louder at the apex, while ( ) S2 is louder at the base.
( ) Pets: _____________________ Stay inside the house? ( ) Yes ( ) No ( ) No murmurs, no thrills, no heaves heard.
Travel Hx: Where: ________________ When: __________________ Abdo ( ) Flat, non-distended. ( ) Umbilicus at the midline.
men ( ) Patient has normoactive bowel sounds. ( ) tympanitic.
( ) No guarding. ( ) No rebound tenderness. ( ) No palpable masses.
REVIEW OF SYSTEMS
( ) No organomegaly. Liver span of _____cm at midclavicular line.
General: ( ) weight loss ( ) fever
( ) irritability ( ) improved appetite & water intake Genit Grossly _______.
Integumentary: ( ) rashes ( ) birthmark alia M: ( ) No hydrocele, ( ) no undescended testes, ( ) no LAD, ( ) inguinal
( ) jaundice hernia ( ) meatus is at tip of penis. ( ) Penis and scrotum at midline.
Head and Neck: ( ) trauma ( ) stiffness ( ) Uncircumcised.
( ) swelling ( ) LAD Extre ( ) No noted inflammations and edema.
Eyes: ( ) discharge mities ( ) Pinkish nailbeds, no clubbing. ( ) With good capillary refill __sec.
( ) tearing ( ) Limbs symmetrical.
( ) redness of the conjunctiva Spine ( ) Spine is at the midline. ( ) No deformities. ( ) No local tenderness.
Ears: ( ) discharge
Nose: ( ) congestion NEUROLOGIC EXAM
( ) epistaxis Cerebral ( ) Pt is euthymic. ( ) Responsive ( ) oriented to TPP
( ) mucus discharge Others:
Mouth and Throat: ( ) soreness Cerebellar ( ) no noted tremors, nystagmus, incoordination, and ataxia
( ) ulcers ( ) nl FTN test ( ) nl HTS test
( ) gum bleeding CN I: ( ) able to react by _______
Respiratory: ( ) hemoptysis ( ) cyanosis ( ) wheezing CN II: ( ) able to see: ________________
( ) cough ( ) tachypnea ( ) able to fix eyes on an object and light
Gastrointestinal: ( ) vomiting ( ) constipation ( ) Pupils 2-3mm ( ) PERRLA
( ) change in bowel habits ( ) melena Jaeger chart: OS: OD:
( ) hematochezia ( )abdominal distention Peripheral vision: ( ) All fields are seen, with good visual tracking.
( ) diarrhea ( ) anorexia Fundoscopy: ( ) Red-orange reflex seen. ( ) OD distinct.
Urinary & Renal: ( ) hematuria ( ) No retinal hemorrhages.
Musculoskeletal ( ) trauma CNIII,IV,VI: ( ) Extraocular movements are fully conjugate with no ptosis
( ) fractures ( ) no nystagmus, ( ) double vision, and ( ) ptosis observed.
Handedness: CN V: ( ) Sensory over the face is intact and equal bilaterally for light
touch (hand) stimuli.
PE FINDINGS ( ) Motor is intact with equal contraction during mastication.
GS CN VII: ( ) Able to raise eyebrows, close eyes against resistance with
( ) alert, ( )awake, oriented to ( ) time, ( ) place, ( ) person ( ) in pain forehead wrinkling, smile, and puff cheeks.
IV line for ______________ on ____________ ( ) nasal cannula ( ) Facial muscle strength is normal and equal bilaterally
Posture: ________Gait:________ Others(body odors): _____________ CN VIII: ( ) Able to hear and locate sound.
Habitus: _____________ IBW: ____ BMI: ______kg/m2 (if BMI>35) ( ) Weber and Rinne Test not assessed.
Waist (M>40in, F>35in): ______ Hip: _____ WHR (M>1, F>0.85): CN IX, X: ( ) Sensory-motor component intact.
Vital BP (nl:110-120/60-75mmHg) ( ) Able to say “lah,” “pah” and “kah.”
Signs: ( ) Able to swallow without difficulty.
PR (nl: 65-110)
( ) No hoarseness of voice observed.
 CN XI: ( ) Able to shrug shoulders and turn head from side to side with attitude toward alcohol and drugs, parental rules; chronically ill physically
resistance. ( ) SCM has good muscle bulk and contour. or mentally challenged parent.
CN XII: ( ) Able to protrude tongue and move it from side to side.
Motor ( ) Good muscle bulk, tone and strength. Friends: peer cliques and configuration “preppies,” “jocks,” “nerds,”
( ) No flaccidity, ( ) no rigidity, and ( ) no atrophy. “computer geeks,” cheerleaders), gang or cult affiliation
UE: R: /5 L: /5 LE: R: /5 L: /5
Findings: IMAGE. Height and weight perceptions, body musculature and physique,
Sensory ( ) 100 % sensation on all extremities. appearance (including dress, jewelry, tattoos, body piercing as fashion
( ) Bilaterally, intact sensory modalities: pain (sharp) & light touch. trends or other statement)
( ) Cortical discrimination intact with localization.
Deep Biceps R( ) L( ) RECREATION. Sleep, exercise, organized or unstructured sports,
Tendon Brachioradialis R( ) L( ) recreational activities (television, video games, computer games, Internet
Reflexes Triceps R( ) L( ) and chat rooms, church or community youth group activities [e.g., Boy/Girl
Patellar R( ) L( ) Scouts; Big Brother/Sister groups, campus groups]). How many hours per
Ankle R( ) L( ) day, days per week involved?
Plantar ( ) Babinski ( ) Gordon ( ) Chadok
Reflexes ( ) Hohenheim ( ) Bing ( ) Gonda SPIRITUALITY AND CONNECTEDNESS. Use HOPE* or FICA† acronym;
Meningeal ( ) Brudzinski ( ) Kernig ( ) Nuchal rigidity adherence, rituals, occult practices, community service or involvement HOPE,
Signs hope or security for the future; organized religion; personal spirituality and
practices; effects on medical care and end of life issues. †FICA, faith beliefs;
importance and influence of faith; community support.
DEVELOPMENTAL MILESTONES
AUTISM: For <2yo
THREATS AND VIOLENCE. Self-harm or harm to others, running away,
( ) Not turning when the parent says the baby’s name
cruelty to animals, guns, fights, arrests, stealing, fire setting, fights in school
( ) Not turning to look when the parent points and says ‘‘Look at . . . ,’’ & not
pointing themselves to show parents an interesting object or event
( ) Lack of back-and-forth babbling
( ) Smiling late
( ) Failure to make eye contact with people

PSYCHOSOCIAL ASSESSMENT FOR ADOLESCENTS (HEADSSFIRST) >13yo

HOME. Space, privacy, frequent geographic moves, neighborhood.
- How are things at home?
- What are your responsibilities?
- Rules that you have to follow?
- Relationship with siblings?
- Do you feel safe at home?

EDUCATION/SCHOOL. Frequent school changes, repetition of a grade/ in

each
subject, teachers’ reports, vocational goals, after-school educational clubs
(language, speech, math, etc.), learning disabilities
- How is school going?
- What grade are you in?
- What school do you go to?
- What subjects are you taking?
- What do you like best? least?
- What are your future plans?
- Do you feel safe at school?
- Have you been involved in any fights?
- Have you ever been suspended? What was that about?

ABUSE. Physical, sexual, emotional, verbal abuse; parental discipline

- Are you involved in any clubs or sports?
- What do you do after school?
- What do you like to do with your friends?
- Are your friends mostly girls? mostly boys? both?

- Do any of your friends use alcohol? Have you ever tried it?
- Lots of kids your age are curious about drinking. How about you?
- You mentioned that you like to go to clubs with your friends. Are any of you
served alcohol there?
- How much, how often, and
whether there have been negative consequences: losing consciousness, DUI, or
a suspension from school.

DRUGS. Tobacco, alcohol, marijuana, inhalants, “club drugs,” “rave”

parties, others. Drug of choice, age at initiation, frequency, mode of intake,
rituals, alone or with peers, quit methods, and number of attempts
- How has your mood been?
- Do you ever find yourself feeling down and sad for more than a few hours?

SAFETY. Seat belts, helmets, sports safety measures, hazardous activities,

driving while intoxicated

SEXUALITY/SEXUAL IDENTITY. Reproductive health (use of contraceptives,

presence of sexually transmitted infections, feelings, pregnancy)

FAMILY AND FRIENDS. Family: Family constellation, genogram, single/

married/separated/divorced/blended family, family occupations and
shifts; history of addiction in 1st- and 2nd-degree relatives, parental