Pediatric Assessment

Name: _________________________________________________ Date: _____________

DOB: ________________ Gestational age at birth: ______________
Age: ____________ Gender: _____________

History

Review of history related to pediatric measurements:

YES/NO If YES, provide details:

Temperature
Recent fever ______________________________________________
Illness during past week ______________________________________________
History of frequent illness or fever _____________________________________________

Pulse
Racing or irregular pulse ______________________________________________
Cardiac disease ______________________________________________
Tires easily with play ______________________________________________

Respirations
Breathing difficulties ______________________________________________
Shortness of breath ______________________________________________
Cough or cold ______________________________________________
Asthma or respiratory problems ______________________________________________
Allergies ______________________________________________
Respiratory meds ______________________________________________

Growth and Development Concerns

History of failure to thrive ______________________________________________
Parent concern for child’s growth ______________________________________________
Meets developmental landmarks _____________________________________________

Family history: _____________________________________________________________________

___________________________________________________________________________________

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 Birth History (for infants)
Gestational age: _______________________________________________________________
Complications of pregnancy: _____________________________________________________
Complications of birthing (bleeding, medications, resuscitation): _________________________
_____________________________________________________________________________
_____________________________________________________________________________
Apgar score (if available): _______________________________________________________
Measurements (length, weight, head and chest circumference) __________________________
_____________________________________________________________________________
Feeding (breast, bottle): _________________________________________________________
Newborn assessment: _________________________________________________________
_____________________________________________________________________________

Medication history: ____________________________________________________________________

_____________________________________________________________________________________

Immunization history: __________________________________________________________________

_____________________________________________________________________________________

Nutrition History
Type and amount of foods eaten (variety, supplements): _______________________________
_______________________________________________________________________________
_______________________________________________________________________________

Eating skills (younger children: bottle, cup, chewing, utensil use; older children: eating patterns):
_______________________________________________________________________________
_______________________________________________________________________________

Eating disorders: ______________________________________________________________

_______________________________________________________________________________

Growth and Development Concerns

History of failure to thrive ______________________________________________
Parent concern for child’s growth______________________________________________
Speech development _______________________________________________
Motor development (creeping, walking, grasping, etc.) ____________________________
School adaptation _________________________________________________________
Social skills for age ________________________________________________________

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 Family support ___________________________________________________________
Safety (age-appropriate carriers, seat belts, protective devices ) _____________________
_________________________________________________________________________
Exposure to violence _______________________________________________________

For the Adolescent

Safety (vehicles, sports, abuse): ____________________________________________________
Social skills: ___________________________________________________________________
Educational progress: ___________________________________________________________
Substance use or exposure: ______________________________________________________
Sexuality (orientation, integration, knowledge, activity, molestation): ________________________
_______________________________________________________________________________
Developmental landmarks: _______________________________________________________

Focused symptom analysis of current problem:

Reason for visit: ___________________________________________________________
_______________________________________________________________________________
Character: ___________________________________________________________
Onset: ___________________________________________________________
Duration: ___________________________________________________________
Location: ___________________________________________________________
Severity: ___________________________________________________________
Associated problems: ___________________________________________________________
Efforts to treat: ___________________________________________________________

Review of Systems (Age-Appropriate)

Allergies (note response): ____________________________________________________________
Skin (lesions, care, and hygiene): _______________________________________________________
Head (injury, convulsions, headache, safety): ______________________________________________
Eyes/vision: ________________________________________________________________________
Ears/hearing: ______________________________________________________________________
Neck, lymph: _______________________________________________________________________
Chest and lungs (asthma, allergies, infections): ____________________________________________
Breast (development, drainage): _______________________________________________________
Heart and cardiovascular: ____________________________________________________________
Abdomen (GI, hernia(s), diabetes): _____________________________________________________
Musculoskeletal (development, injuries, sports, safety): _____________________________________
Neurological (developmental landmarks, language): ________________________________________

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 Mental health (retardation, ADHD, depression, OCD, anxiety): ________________________________
___________________________________________________________________________________
GU (number of wet diapers, pain, itching): _________________________________________________
Reproductive (appropriate genitalia, sexual activity, menarche, circumcision, abuse): ______________
___________________________________________________________________________________

Last Assessment Recorded

Date: ______________________

Record last assessment findings.

Temperature __________ method _________ Height/Length _________________
Pulse ___________________ Weight _________________
Respirations ___________________ Infants: _________________
Blood Pressure ___________________ Head Circumference _________________
BMI Chest Circumference _________________

Physical Assessment
Approach young children in order of procedures that require their cooperation, as they can
become tired and/or uncooperative.

Vital Signs
DATE OF ASSESSMENT

Date

Temperature
O = Oral
A = Apical
R = Rectal
T = Tympanic

Pulse
R = Radial
A = Apical

Rhythm

Respirations
Pressure

Systolic
Blood

Diastolic

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Measurements for Young Children
DATE OF ASSESSMENT

Date

Height or Length

Kg
Weight
Lb

BMI

Evaluate until 1 year of age

Circumference, Head
(Measure in cm)

Head: Fontanels

Circumference, Chest
(Measure in cm)

Circumference,
Abdomen
(Measure in cm)

Also, plot the child’s growth on one of the national standardized growth graphs.
Consider standardized tools for assessment of development, such as the Denver Development II.

Performance of the physical exam is much like that for the adult. Findings will differ significantly for
various ages. (Please see text Chapter 25 for expected variations.

Skin (lesions, care, and hygiene): _______________________________________________________

Head (size, shape, fontanels (with infant), scalp, infestations, bruises): __________________________
___________________________________________________________________________________

Eyes/vision (physical exam, red light reflex for infants, Snellen’s, cover/uncover for older child): ______
___________________________________________________________________________________

Ears/hearing (physical exam, placement, whisper, audiometry (if available)): _____________________

___________________________________________________________________________________

Neck, lymph: _______________________________________________________________________

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©2006 Pearson Education, Inc.
 Chest and lungs: ___________________________________________________________________

Breast (development, drainage, BSE (for adolescent)): _______________________________________

___________________________________________________________________________________

Heart and cardiovascular: ____________________________________________________________

___________________________________________________________________________________

Abdomen (hernia(s), organomegaly): ____________________________________________________

Musculoskeletal: ___________________________________________________________________

Neurological (reflexes appropriate to age, developmental landmarks, language): __________________

__________________________________________________________________________________

Mental health (orientation, behavior): ____________________________________________________

___________________________________________________________________________________

Reproductive/urinary (appropriate genitalia, vaginal discharge, urethral placement, descended

testicles, signs of abuse, signs of STD, pregnancy): _________________________________________
___________________________________________________________________________________

Analysis:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

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