PEDIATRICS HISTORY TAKING AND PE FORM (based from Navarro)

Date and Time of Interview: Informant and Reliability:

I. IDENTIFYING DATA

Name of Patient
Age Sex
Birthdate Birthplace
Religion Ethnicity
Current address
# of hospital
admissions and
institution

II. CHIEF COMPLAINT:

III. HISTORY OF PRESENT ILLNESS

IV. PAST PERSONAL HISTORY

*Parts A, B, C should only be asked if patient is <2 yrs old or in > 2 yrs old if the chief complaint and HPI is
related to the illness.

A. GESTATIONAL HISTORY

Mother’ age during OB Score

pregnancy
Prenatal care (how
often? Where?
Duration of pregnancy Health conditions
during pregnancy
Xray exposure Supplements/Nutrition
Intake of any drugs? Immunization

B. BIRTH HISTORY

Term/Preterm/Post- Manner of delivery

term?
Attendant Birth weight
Place/institution

C. NEONATAL HISTORTY

APGAR Score BALLARD Score

Good cry? Spontaneous
respiration/required
resuscitation?
Ask for cyanosis, pallor, jaundice, convulsions,
hemorrhage, feeding difficulties, birth injury,
congenital anomalies

D. FEEDING HISTORY
i. INFANTS (<2 yrs old)

Type of Feeding
If BF, duration per breast,
frequency per day
If formula feeding/mixed
feeding, formula milk type,
dilution, frequency, bottle fed or
cup fed?, reason for formula
feeding/mixed feeding
Complementary foods: age,
usual food, freq and amount
 ii. Children and Adolescents

Typical meal and

amount
Appetite: picky eater/
good appetite?

E. DEVELOPMENTAL/BEHAVIORAL HISTORY
i. Milestones

ii. For 1-5 y/o ask the following:

Dental eruption Urinary incontinence?

Beginning and
completion of toilet
training
Tantrums, head
banging, phobias, pica,
night terrors, sleep
disturbances?

iii. Middle childhood, ask for:

School Performance
Sexual development
(Tanner Maturity
Rating)

iv. Adolescence (10-20 y/o)

Home
Education
Eating behavior/habits
 Activity
Drugs
Sexual
Suicidal ideations
SMR (if female, include menstrual
hx)

F. PAST ILLNESSES

Major medical illnesses

Major surgical illnesses
Trauma/Fractures/Accidents
Hospitalizations (Dx and dates)
Current medications
Known allergies

V. IMMUNIZATION HISTORY (list vaccines received and doses)

VI. FAMILY HISTORY

Parent’s age and occupation:

Siblings and age:

Ask for:

A. Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and
asthma, epilepsy

B. Mental retardation, congenital anomalies, chromosomal problems, growth problems, consanguinity,

ethnic background

VII. SOCIO ECONOMIC HISTORY

Living circumstances
Place Nature of Dwelling
# of persons living in (Describe house,
the house #rooms, windows,
toilet)
Economic circumstances
Working members of Source of funds
the family
VIII. ENVIRONMENTAL HISTORY

Electricity
Water (drinking and utilities)
Cigarette smoking exposures
Fumes
Garbage disposal
Pets

IX. REVIEW OF SYSTEMS

Skin and Lymph Nodes: (-) itchiness, (-) excessive dryness or sweating, (-) cyanosis, (-) pallor, (-)

jaundice, (-) erythema, (-) bruising, (-) bleeding, (-) lumps

Head: (-) headache, (-) dizziness, (-) vertigo

Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-) excessive lacrimation, (-)

photophobia, (-) use of reading glasses

Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge, (-) mass, (-) cerumen

Nose and Sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-)

nasal discharge, (-) pain over paranasal sinuses

Mouth and Throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-)

hoarseness, (-) mouth breathing, (-) snoring, (-) dyspnea, (-) caries

Neck: (-) pain, (-) limitation of movement, (-) mass

Breast: (-) pain, (-) lumps, (-) nipple discharge

Respiratory: (-) pleuritic chest pain, (-) cough, (-) sputum production, (-) hemoptysis, (-)

audible wheezing
Cardiovascular: (-) palpitations, (-) syncope, (-) easy fatigability

Gastrointestinal:, (-) nausea, (-) dysphagia, (-) diarrhea (caused by suppository), (-) constipation,

(-) hematemesis, (-) melena, (-) hematochezia, (-) regurgitation, (-) vomiting, (-) epigastric pain

Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-)

incontinence, (-) genital pruritus, (-) urethral discharge

Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) intermittent

claudication, (-) limitation of movement

Nervous: (-) headache, (-) vertigo, (-) syncope, (-) loss of consciousness, (-) focal weakness, (-)

paralysis, (-) numbness, (-) paresthesia, (-) speech disorder, (-) loss of memory, (-) confusion

Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising

Endocrine: (-) intolerance to heat and cold; (-) polydipsia