PEDIATRICS HISTORY TAKING

PATIENT’S PROFILE

Name: __________________ Age: ______ DOB: ___________________

Gender: ___________Address: _________________________________
DOA: ______________________ MOA: __________________________
Historian: ___________________

PRESENTING COMPLAINT

1. __________________________________________________
2. __________________________________________________
3. __________________________________________________

KNOWN CASE OF ________________________________________

HISTORY OF PRESENT ILLNESS

Site:
Onset:
Duration:
Frequency:
Progression:
Character:
Intensity:
Aggravating factors:
Relieving factors:
Associated symptoms:

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

SYSTEMIC REVIEW

a) General (weight loss, gain, appetite, sleep)

b) CVS (shortness of breath on exertion, SOB and sweaty on feeding,
cyanotic spells, squatting, fainting or syncope, cyanosis, edema,
chest pain, palpitations)
c) Respiratory system (sore throat, earache, cough, wheeze,
frequent chest infections, history of aspiration, hemoptysis)
d) GIT (abdominal pain, vomiting, jaundice, diarrhea/constipation,
blood in stools)
e) CNS (fits, syncope/dizziness, headache, visual problems,
numbness, unpleasant sensations, weakness, frequent falls,
incontinence)
f) Genitourinary system (stream, dysuria, frequency,
nocturia/enuresis, incontinence, hematuria)
g) Rheumatological system (limp, joint swelling, hair loss, skin rash,
dry mouth/mouth ulcers, dry or sore eyes, cold extremities)

COURSE OF ILLNESS

Patient was admitted _____ days back, _____________________

tests done, ______________________ medications were started.
Patient’s condition static/improved/deteriorated. Knowledge of
mother about his condition is fair/weak.

PAST HISTORY

Medical:

Surgical:

Drugs:

*Important in patients with chronic disease

When ______________ diagnosed where ___________________

How was it diagnosed ___________________________________
Previous hospital admission ______________________________
 BIRTH HISTORY

Antenatal: age of mother, antenatal visits, health and nutritional status

of mother during pregnancy, complications: HTN, DM, pre-eclampsia,
TORCH infections, regular antenatal scans (normal/abnormal)

Natal: hospital/home birth, SVD/C-section, term/preterm/post term

Postnatal: 1st cry (immediately, cyanosed, apneic), weight, nursery stay,

jaundice, fever, rash

FEEDING HISTORY

o Onset: after ____________ hours

o Type: breast-fed/bottle-fed (formula)
o Weaning
o Current diet

IMMUNIZATION HISTORY

Did he get vaccinated? _______

*Check vaccination card
Types of vaccines: ____________________
Age: ____________________
Doses: ____________________
If any Adverse effects: ______________

o Unvaccinated
o Partially vaccinated
o Up to date
o Fully vaccinated

DEVELOPMENTAL HISTORY

Achieving age of milestones:

Gross motor (smiling, sit, crawl, standing, walking) ______
Fine motor + vision
o pincer grasp
o ulnar grasp
o drawing a circle
Hearing & speech
Behavior
o stranger anxiety
o social activities (peak a boo, bye bye)
Control of bladder and bowel
 FAMILY HISTORY

Age of mother and father? _________ married for _________

• Cousin marriage
Siblings
• Number ______
• No. of this child ______
• Illness in other siblings if any ________

• HTN
• DM
• Thalassemia
• Contact of TB
Genetic conditions: __________________________

SOCIOECONOMIC HISTORY

Father’s occupation: ____________ & education: __________

Mother’s occupation: ____________ & education: __________
House: _______________ members: ___________
Source of drinking water: tap/filtered/packaged

ENVIRONMENTAL HISTORY

General hygiene conditions

Any pets at home