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    (Post Test - 5 Points) : Environmental Background

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    Kristil Chavez
    This document contains the pediatric record of an unnamed patient including their family history, prenatal history, growth and development, immunization history, past medical history, and treatment record. Sections include information on the patient's parents, siblings, medical conditions that run in the family, the home environment, pregnancies, deliveries, newborn screening, feeding, developmental milestones, schooling, immunizations received, menstrual history for female patients, and past hospitalizations, diagnoses, and treatments. The treatment record section documents each visit with the chief complaint, diagnosis, treatment provided, and any remarks.

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    (Post Test - 5 Points) : Environmental Background

    Uploaded by

    Kristil Chavez
    10 views2 pages
    This document contains the pediatric record of an unnamed patient including their family history, prenatal history, growth and development, immunization history, past medical history, and treatment record. Sections include information on the patient's parents, siblings, medical conditions that run in the family, the home environment, pregnancies, deliveries, newborn screening, feeding, developmental milestones, schooling, immunizations received, menstrual history for female patients, and past hospitalizations, diagnoses, and treatments. The treatment record section documents each visit with the chief complaint, diagnosis, treatment provided, and any remarks.

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    OPD Chart Students Copy

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    This document contains the pediatric record of an unnamed patient including their family history, prenatal history, growth and development, immunization history, past medical history, and treatment record. Sections include information on the patient's parents, siblings, medical conditions that run in the family, the home environment, pregnancies, deliveries, newborn screening, feeding, developmental milestones, schooling, immunizations received, menstrual history for female patients, and past hospitalizations, diagnoses, and treatments. The treatment record section documents each visit with the chief complaint, diagnosis, treatment provided, and any remarks.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    10 views2 pages

    (Post Test - 5 Points) : Environmental Background

    Uploaded by

    Kristil Chavez
    This document contains the pediatric record of an unnamed patient including their family history, prenatal history, growth and development, immunization history, past medical history, and treatment record. Sections include information on the patient's parents, siblings, medical conditions that run in the family, the home environment, pregnancies, deliveries, newborn screening, feeding, developmental milestones, schooling, immunizations received, menstrual history for female patients, and past hospitalizations, diagnoses, and treatments. The treatment record section documents each visit with the chief complaint, diagnosis, treatment provided, and any remarks.

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    of 2

    (Post test – 5 Points)

    OPD PEDIATRIC RECORD

    Name of Patient ____________________________________ Hospital No. __________________ Date ______________


    Date of Birth __________________ Age ___________________ Sex ______________________
    Attending Physician _______________________________________

    FAMILY HISTORY
    Father _______________________ Age________ Occupation _______________________
    Mother_______________________ Age_________ Occupation________________________
    No. Of Siblings _________________________

    TB Hypertension Asthma Convulsions Diabetes Allergy Malignancy

    Others _______________________

    Environmental Background
    House _________________________ Toilet _______________________ Water Supply __________________________
    Exposure to:
    Chemicals________________ Pets ____________________Radiation ___________________ Others_____________
    History of Pregnancy
    Pre-Natal____________________ Place ________________________ Attended by ___________________________
    Medications ____________________ _Illness ________________________ Exposure _____________________________
    Natal
    Types of Delivery __________________Place ________________________Apgar ____________________________
    AOG ____________________________ WT _________ LT____________ HC________________ CC_______________
    Attended by _____________________ NB Screening __________________________
    Meconium____________________ ___First Voiding __________________Jaundice ___________________
    Feeding
    BF ___________________ __________MF _________________________ Dilution _______________________

    GROWTH AND DEVELOPMENT


    (Developmental Concerns) IMMUNIZATION
    1st 2nd 3rd Booster Booster

    Gross Motor ________________ BCG

    Fine Motor ________________ Hepatitis B

    Receptive Language ________________ Pentavalent Vaccine (DPT,Hep B, HiB)

    Expressive Language________________ Oral Polio Vaccine (OPV)

    Cognitive ________________ Inactivated Polio Vaccine(IPV)

    Adaptive ________________ Pneumoccocal Conjugate Vaccine (PCV)

    Personal/Social ________________ Measles, Mumps, Rubella

    School Level ______________________

    MENSTRUAL HISTORY

    Menarche _____________________________ Quantity ____________________________________


    Duration _____________________________ Frequency ____________________________________
    LMP _____________________________ Dysmenorrhea ____________________________________

    PAST MEDICAL HISTORY

    Date Hospital Diagnosis Disposition Meds


    For OPD Pedia Scenario
    (5 points)
    OUTPATIENT DEPARTMENT

    TREATMENT RECORD AND PROGRESS NOTES

    Name:___________________________________________ Age ___________Sex __________Hospital No,___________________

    Date & Time Chief Complaint Diagnosis Service/Treatment/Procedure Remarks (Special


    Vital Signs Rendered/Labs. Instructions)

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