INDIVIDUAL HEALTH RECORD

Child No. PHO418____________________ Date: ___________________________

Child Name:________________________________ Age: ________ Sex:________________

Vital Signs:

BP: _______________ Weight:____________ Height:_______________

Chief Complaint:

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History of Present Illness:

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Physical Examination:

General Survey:

Skin:

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Head/Eyes/Ears/Nose:

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Mouth/Throat:

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Neck:

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Chest/Back:

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Lungs:

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Heart:

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Abdomen:

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Extremities:

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Bones/Joint/Muscles:

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Neurological Reflexes:

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Assessment/Diagnosis:

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PLAN:

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