HISTORY AND PE SHEET ● route

● was there relief?

IDENTIFYING DATA ● home
remedies/herbal
Name:
Associated symptoms:
Age:
Allergies, if any:
Sex:
Any vices? (Smoking,
Religion: Alcohol drinking, Drugs) if
yes, indicate how long has
Address: the patient been using

CC:

OTHER NOTES OTHER NOTES

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY
Onset:
Previous illnesses:
Presence of pain (if yes, ● diabetes
indicate pain score): ● hypertension
● asthma
Location: ● hepatitis
● HIV
Duration: ● infections
● cough and colds
Characteristics: ● etc

Aggravating: Previous hospitalization:

● age/year of
Relieving: hospitalization
● length of stay
Timing: ● reason
● hospital where
Medications taken: admitted
● self prescribed?
● name of meds Previous Surgeries
● dose and frequency ● transfusions
 ● age/year of surgery
● reason
● complications, if any

Previous history of: PEDIA: PREGNANCY AND BIRTH HISTORY

● injury
● trauma Antenatal
● accidents ● health of mom during
pregnancy
Maintenance ● prenatal consultations
medications: ● complications
● name (infections/illness/blee
● dose/frequency ding/trauma)
● route ● mom’s previous
pregnancy hx
OTHER NOTES
Natal
● duration of pregnancy
(preterm, full term,
post term)
FAMILY HISTORY ● birth weight
delivery
Any members with the ● location
same symptoms? ● type (vaginal/CS)
● if vaginal,
Heredofamilial diseases spontaneous or
● TB induced?
● Asthma ● presentation
● Hypertension (vertex/breech):
● Coronary heart ● sedation/anesthesia
diseases state of infant at birth
● Stroke ● was resuscitation
● Diabetes required?
● Thyroid/renal disease ● onset of respiration
● Arthritis ● first cry
● Cancer
● Anemia Neonatal
● Genetic illnesses ● APGAR score
● Allergies ● NBS results
● Conge anomalies (cleft
lip) OTHER NOTES
● Epilepsy

OTHER NOTES
 PEDIA: DEVELOPMENTAL HISTORY

Motor skills
● first raised head
● roll over IMMUNIZATIONS
● crawl
● sit alone BCG (Birth, deltoid)
● pulled up
● walk with support Hep B (Birth, 6W,14W)
● walk alone
● first word DtwP, Hib-Hep
● talked (meaningful)
Pentavalent
● toilet trained
(6W,10W,14W), Dpt
Physical
OPV (6W,10W,14W)
● pubertal development
if female:
Oral Polio (drops)
● obstetric hx
● menstrual hx
Measles (9M)
● contraceptives
● sexual function
● screening tests (tb
Rotavirus (6W,10W)
test, pap smear,
mammogram, stool
Others
test for occult
bleeding,
colonoscopy,
cholesterol tests)
PERSONAL AND SOCIAL HISTORY
Nutrition
● breastfed? if yes, Occupation/Schooling:
how long? if not,
indicate formula Schooling appropriate for
type age?
● start of
Job history:
complementary
feeding
Home situation:
● vitamins
● usual diet Father’s name:
● appetite
● last deworming Father’s age

OTHER NOTES Father’s occupation

Mother’s name: weakness

Mother’s age: Skin

rashes
Mother’s occupation: lump
sore
Mother’s age during itching
pregnancy: dryness
change in color
Siblings
easy bruising

Head
headaches
dizziness
trauma

Eyes
Pets: change in eyesight
vision
Hobbies:
eyeglasses
pain
ENVIRONMENTAL STATUS
redness
Water supply flashing lights
glaucoma
House location cataracts
● factories near
● riverside
Ears
OTHER NOTES hearing loss
pain
discharges
tinnitus
vertigo
REVIEW OF SYMPTOMS hearing aids
myringotomy tube
General placement
fever hx OM
chills hx OE
malaise
fatigue Nose
weight change colds
(sudden, progressive)
 obstructions/foreign Cardiovascular System
body chest pain
sinus pain palpitations
itching fatigue
bleeding HPN
cyanosis
Teeth & Mouth heartburn
pain high BP
hoarseness
soreness Gastrointestinal System
dysphagia appetite
odynophagia N/V
change in taste bowel movements
bleeding gums stool (color, volume,
dentures consistency)
dry mouth diarrhea
sore tongue constipation
abdominal pain
Neck food intolerance
swollen glands vomiting (bilious,
goiter/lumps bloody)
stiffness describe diet
LAD
pain Genito-urinary Tract
dysuria
Chest and Lungs flank pain
pain urgency
dyspnea polyuria
cough pain
sputum (color) hematuria
wheezing vaginal discharges
pleurisy itching
asthma spurs
bronchitis lumps
apnea urine (color,
stridor frequency, volume)

Breasts Musculoskeletal System

discharges joint pain
pain/tenderness stiffness
lumps weakness
 tremors comatosed
swelling ambulatory
dec ROM pain (indicate score)
leg cramps fever
varicose veins respiratory distress
redness nourished
history of trauma well-developed
(specify)
back pain Vital signs
edema
deformities Temperature

Hema Heart rate

bleeding
Respiratory Rate
anemia
bruising
Blood pressure

Neuro
Weight
loss of coordination
syncope Height
changes in sensorium
nervousness HEENT
memory change
depression Head
hyperactivity normocephalic
gait trauma
pain
OTHER NOTES bloody discharges
abrasions and
lacerations
tenderness
headache
PHYSICAL EXAMINATION
Eyes
General Survey PERLA
conscious Pale conjunctiva
coherent Pink conjunctiva
alert Icterus
lethargic cataracts
obtunded discharges
stuporous pain
 white sclera abnormal retractions
use of accessory
Ears muscles
symmetrical Palpation:
discharges equal tactile fremitus
pain Percussion:
lesions resonant lung fields
normally developed Auscultation:
breath sounds
Nose wheezing
symmetrical rales
discharges bronchovesicular
obstructions sounds
flaring
sinus pain Cardiovascular System
Inspection:
Teeth and Mouth PMI at 5th ICS left
ulceration midclavicular line
swelling Palpation:
discharges PMI, no thrills, no
midline heaves
lymphadenopathies Percussion:
JVD cardiac area of
tonsils not enlarged dullness not enlarged
lesions Auscultation:
good dentition regular heart rate and
rhythm
Neck no murmurs
no LAD
masses Abdomen
tenderness Inspection:
trachea at midline no scars, abrasions,
lacerations on skin
Chest and Lungs flat
Inspection: rounded/globular
symmetrical scaphoid
equal bilateral distended
expansion Auscultation:
abrasions normoactive bowel
lesions sounds
lacerations Percussion:
 mild tympany
tenderness
Palpation:
organomegaly (spleen,
liver)

Genit-urinary
appropriate for age
lesions
discharges
inguinal masses
pain/tenderness
normal genitalia

Extremities
peripheral pulses
CRT
cyanosis
warm
cold/clammy
scars
dry skin
sweaty skin
oily skin
rough skin
smooth skin
Nails cyanosis
Nail clubbing
Joint swelling
Edema

OTHER NOTES