HISTORY TAKING- PAEDIATRICS

PERSONAL INFORMATION

Name:
ID:
Age:
Sex:
Race:
Address:
DOB:
Referral:
Informant:
DOA:
DOD:
DOC:

CHIEF COMPLAIN

Sympton:____________ Duration:__________

HISTORY OF PRESENTING ILLNESSES

Onset:
Site:
Radiation:
Character:
Aggravating factor:
Relieving factor:
Severity:
Associating factor:
Time coarse:
Extra: What was the patient doing before the attack started:
What did the parents do?
SYSTEMIC REVIEW

General health- How active and lively?

Normal growth- Is the child following their weigh and height centiles?
Weight_______ Height_________

Any recent change in behaviour or personality?

General rashes:
Fever:
Respiratory-Cough,wheeze, noisy breathing, Difficulty in breathing
Earache:
Throat infections:
CVS- Cyanosis, Exercise tolerance, faints, palpitation
GIT- Vomiting, diarrhoea, Constipation, abdominal pain, Poor appetite,
hematemesis, malena, dysphagia
Genitourinary- Dysuria, frequency,wetting,Toilet-trained
Neurological- Vision, hearing, seizures,headaches, change in behaviour,
impaired or abnormal movement.
MSK- Limb pain, swelling

PAST MEDICAL HISTORY

Antenatal
Illness or complication during gestation period:
Perinatal
Delivery complication (Fetal distress, vacuumn delivery, Hypoxic insult) :
Prematurity:
Birth weight:
Neonatal
Illness or admission:
Medical condition:
Previous hospitalization:
Previous surgery:
Accidents/ Injuries:
FEEDING

Breast feeding:
Bottle feeding:
Vomitting/ diarrhea/ regurgitation:
Solid foods?
Complimentary diet?
Adult diet?
How many ounces of milk?
Frequency of feeding?

IMMUNISATION HISTORY
How many vaccines so far and their names

DEVELOPMENT HISTORY
Gross motor
Sits unsupported
Walks around furniture
Walks unaided

Fine motor and vision:

Follows a face
Reaches for toys
Grasps with palmar grip
Picks up small objects

Speech, language and hearing

Startles to loud noises

Coos and babbles
Turns head to sounds
Says ‘mama’, ‘dada’
Understands commands
Says words (how many?)
Talks in sentences
Social, emotional, and behavioral

Smiles
Feeds himself solid food
Drinks from a cup
Helps with tasks like dressing
Toilet- trained

Others:

Development milestones
Sitting up:
Crawling:
Walking
Talking:
Toilet trained:
Reading:

Bladder and bowel control:

Child’d temperament and behavior:
Sleeping problems:

DRUG HISTORY
Allergies-
Regular medication-
OTC-

FAMILY HISTORY

Have any members of the family or friends had similar problems?

Genetic conditions

Mother Father M. side F. side

Diabetes
Cancer
Hypertension
Myocardial. I
Asthma

SOCIAL HISTORY

Mother’s occupation:
Father’s occupation:
Economic status:
Parental smoking:
Who takes care of the baby:
Alcohol or drug abuse:
Cramped housing:
Long term unemployment: