Pediatric history taking

Name ………………………………………………………………………………………………………...
Sex …………………………………………………………………………………………………………
Age ………………………………………………………………………………………………………...
Nationality …………………………………………………………………………………………………..
Source of history ……………………………………………………………………………………………

History of presenting illness

Introduction ………. previously well/ known to have……………………………………………………..

Chief complaint (chronological order- since how long for each complaint)
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Analysis of chief complaint
Was the child well before? Yes/No …………………………………………………………………………
Site …………………………………………………………………………………………………………..
Onset of illness (Acute/Gradual) …………………………………………………………………………….
Duration ……………………………………………………………………………………………………..
Character …………………………………………………………………………………………………….
Radiation …………………………………………………………………………………………………….
Associated symptoms ………………………………………………………………………………………..
Exacerbating/Relieving factors ……………………………………………………………………………..
Severity ……………………………………………………………………………………………………..

Progress during the illness (beginning of chief complaint till the time of seeing the patient last)
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Systemic review (apart from chief complaints)

Positives Important negatives

Check end of doc for a checklist!

Past medical history

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First time? Yes/No
Drug history …………………………………………………………………………………………………
Allergies/ Drug allergy …………………..………………………………………………………………….
Infections ……………………………………………………………………………………………………
Hospitalization ………………………………………………………………………………………………
Operations …………………………………………………………………………………………………...
Circumcision ………………………………………………………………………………………………...

Birth and neonatal history

Prenatal
Any disease the mother had while pregnant? (Diabetic/chronic diseases/on any drugs)

Natal
Type of delivery ……………………………………………………………………………………………..
Preterm? (Yes/No) …………………………………………………………………………………………
Birth weight (AGA/SGA/LGA) ..…………………………………………………………………………..
Condition of the infant at birth ………………………………………………………………………………
Cried at birth? (Yes/No)
Resuscitation?
Admission after birth

Neonatal
Condition of baby after birth and 1st month of life
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Congenital abnormalities ………………………………………………………………………………….
Birth injuries ………………………………………………………………………………………………
Difficulty feeding/sucking? (Yes/No)
NICU?
Development history

Did Does
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Any unusual growth/failure to grow? (Yes/No)
Comparison of growth with siblings ………………………………………………………………………..
Recent or current milestones ………………………………………………………………………………...
Developmental milestones (Gross motor; Fine motor; Language; Cognition)
Check end of doc for a checklist!
School performance …………………………………………………………………………………………
Growth is (age-appropriate/delayed/regressive)

Nutrition/Diet history (asked especially in malnourished/immunocompromised child)

Feeding (Breast/formula- started when, mixed?) …………………………………………………………...

Weaning (when, type)……………………………………………………………………………………….
Solid food (when, type) ……………………………………………………………………………………..
Supplements (type, when, amount, duration) ………………………………………………………………
Food allergies (patient/family)……………………………………………………………………………….
Present diet …………………………………………………………………………………………………..

Immunization

Is vaccination done? (Yes/No) ………………………………………………………………………………

When was the last vaccine and for what? …………………………………………………………………..
Reaction /allergy (Yes/No)......………………………………………………………………………………

Family history

Consanguinity (Yes/No) ……………………………………………………………………………………..

Health conditions of parents …………………………………………………………………………………
Siblings health conditions …………………………………………………………………………………...
Family illness/chronic disease ………………………………………………………………………………

Social history

Living condition ……………………………………………………………………………………………

Insurance/financial issues …………………………………………………………………………………..
Presence of infections (Yes/No) ……………………………………………………………………………
Pets? (Yes/No) ……………………………………………………………………………………………..
 REVIEW OF SYSTEMS
(ask questions appropriate to system)

General: Cardiovascular:
❑ Fever ❑ Chest pain
❑ Weight loss ❑ Shortness of breath
❑ Fatigue ❑ Swelling of the feet
❑ Loss of Appetite ❑ Cyanosis
❑ Sleep disturbance ❑ Palpitations
❑ Chills ❑ Irregular heart beat
❑ Night Sweats ❑ None
❑ None

Endocrine: Gastrointestinal:
❑ Excess thirst/hunger ❑ Abdominal pain
❑ Excessive urination ❑ Vomiting
❑ Heat Intolerance ❑ Nausea
❑ Cold Intolerance ❑ Diarrhea
❑ Hair loss ❑ Bloody stools
❑ Dry skin ❑ Stomach Ulcers
❑ Weight changes ❑ Constipation
❑ None ❑ Trouble Swallowing
❑ Jaundice/yellow skin
❑ Urine!
❑ None

Genitourinary: Hematology/Oncology:
❑ Frequency ❑ Easy bruising
❑ Urgency ❑ Prolonged bleeding
❑ Hesitancy ❑ None
❑ Pain/ burning micturition
❑ Fever
❑ Bed wetting/ incontinence
❑ Kidney stones
❑ Painful/difficult urination
❑ Urinary discharge/ blood
❑ None
HENT: Integumentary:
❑ Hearing loss ❑ Rash
❑ Sore throat ❑ Change in mole
❑ Runny nose ❑ Skin sores
❑ Epistaxis ❑ Severe itching
❑ Dry mouth ❑ Loss of hair
❑ Jaw Claudication (pain in ❑ None
jaw when chewing)
❑ Ear ache
❑ Mouth breathing
❑ Snoring
❑ None

Musculoskeletal: Neurologic:
❑ Muscle aches ❑ Weakness
❑ Joint pain ❑ Headaches
❑ Difficulty laying flat due ❑ Dizziness
to muscle pain ❑ Paralysis of extremities
❑ Back pain ❑ Tremor
❑ Gait ❑ Stroke
❑ None ❑ Numbness or tingling
❑ Seizures or convulsions
❑ Speech
❑ Fainting
❑ None

Respiratory:
❑ Wheezing
❑ Cough (sputum/blood)
❑ Sneeze
❑ Severe or Frequent colds/ sore throat
❑ Fever
❑ Difficulty breathing
❑ Cyanosis
❑ Orthopnea
❑ None
DEVELOPMENTAL MILESTONES