Pediatric history format

Identification (ID):
 Name
 Age/Date of Birth
 Sex
 Religion
 IPD no.
 Informant ( Reliability)
 Parent’s name, age, address, education,
 Provisional clinical impression
 Final diagnosis

Chief Complaints (CC):

 Symptoms at the time of admission, Duration in Chronological order

History of Presenting Illness (HPI):

 Symptoms: Location, quality, quantity, aggravating and alleviating factors
 Time course: Onset, duration, frequency, change over time
 Rx/Intervention: Medications, medical help sought, other actions taken
 Etiology and risk factors

History of Past Illness:

 Date and Interventions for: Respiratory tract infections, Gastrointestinal infections,
Previous similar episodes, Any significant disease, accidents or injuries, Foreign body
 Hospitalizations
 Surgeries

Perinatal History:
 Pregnancy (Antenatal): Gravida/Para status, Maternal age, Duration, Exposures
(medications, alcohol, tobacco, drugs, infections, radiation), Complications (Bleeding,
Diabetes, Hypertension), Problems with previous pregnancies, Occurred on contraception?
Planned?
 Labor and Delivery (Natal): Length of labor, Rupture of membrane, Fetal movement,
Medications, Presentation, Mode of delivery, Assistance (Forceps, vacuum), Complications,
APGARs, Immediate breathe/cry, Oxygen requirement, Intubation and duration
 Neonatal (Postnatal): Birth height and weight, Abnormalities, Injuries, Length of
hospital stay, Complications (Respiratory Distress Syndrome, Cyanosis, Anemia, Jaundice,
Seizures, Anomalies, Infections), Behavior
Development History:
Anthropometric assessment:
Anthropometric Patient range Normal range Remark
parameters
Height
Weight
Head circumference
Chest circumference
Mid upper arm
circumference

Developmental milestone:
 Assess each of the 4 areas individually in order: Gross motor, Fine motor, Language,
Personal social
 Ask the milestone which you expect the child to achieve at that age
 If the child has acquired these functions, the development can be considered as normal.
State as follows: The development of this __ months old child matches the chronological
age in all 4 spheres of development.
 If the child has not acquired the desired function, ask for a function that the child would
have achieved by an earlier age, in that particular sphere of development. State as follows:
The development of this __ months old child in the __ area corresponds to a chronological
age of between __ to __ months.
 Try to find out etiology through perinatal, family or social history, if there is
developmental delay

Family history:
 Family tree
 Family description
Name Age/sex Relation with Health status Remark
patient

Socioeconomic status history:

 Parent’s education and occupation, living arrangements, pets, water supply, lead exposure
(old house, paint), Smoke exposure, religion, finances, family dynamics, risk taking
behaviors, school/daycare, other caregivers

Nutritional history:
 When was the 1st feed given?
 Whether baby received any prelacteal feeds?
 How many times breast-feed is given in last 24 hours?
 How many night feeds were given?
 *Does the child receive any other food or drink in addition to breastfeeds? If yes which
food and drink?
 If animal milk/formula milk: how many times in last 24 hours? Dilution?
 What is being used to feed the child if baby is receiving feed other than breastfeeds:
cup/spoon/bottle?
 How feeding bottle/cup is prepared: washing? Boiling?
 How many times baby is passing urine in 24 hours?
 What is the color of urine?
 Ask mother if she has any pain during breastfeeding?

Immunizations:
 up to date, reactions

Physical examination:
Review of Systems (ROS):
 General—fever, activity, growth
 Head—trauma, size, shape
 Eyes—erythema, drainage, acuity, tearing, trauma
 Ears—infection, drainage, hearing
 Nose—drainage, congestion, sneezing, bleeding, frequent colds
 Mouth—eruption/condition of teeth, lesions, infection, odor
 Throat—sore, tonsils, recurrent strep pharyngitis
 Neck—stiff, lumps, tenderness
 Respiratory—cough, wheeze, chest pain, pneumonia, retractions, apnea, stridor
 Cardiovascular—murmur, exercise intolerance, diaphoresis, syncope
 Gastrointestinal—appetite, constipation, diarrhea, poor suck, swallow, abdominal pain,
jaundice, vomiting, change in bowel movements, blood, food intolerances
 GU—urine output, stream, urgency, frequency, discharge, blood, fussy during
menstruation, sexually active
 Endocrine—polyuria/polydipsia/polyphagia, puberty, thyroid, growth/stature
 Musculoskeletal—pain, swelling, redness, warmth, movement, trauma
 Neurologic—headache, dizziness, convulsions, visual changes, loss of consciousness,
gait, coordination, handedness
 Skin—bruises, rash, itching, hair loss, color (cyanosis)

Summary of the case:

Investigation:
Sr. Name of examination Patient value Normal value Remark
No

Medications:
Sr. no Name of drugs Dose / time Route Action
Care plan