SBUCM PEDIATRIC MEDICAL HISTORY-PE FORM

Name of Student: Date:

I. General Data:

Gender Area of encounter

Patient’s Initials Age Informant Reliability
M/F (OPD/WARD/NEO)

II. Chief Complaint: fever cough colds diarrhea rash others:

III. History of Present Illness:

IV. Review of Systems:

Check if asked Write Positive symptoms:

General

Cutaneous

Head (including eyes, ears,

nose, mouth, and throat)

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Endocrine

Nervous/Behavioral

Musculoskeletal

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Hematopoeietic

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For the following parts, write important information only.

V. Past Personal History:

___A. Birth/Maternal history

Born to a year old, G_P_(__-__-__-__) Delivered via reason if CS

Prenatal check-up since month AOG, at at assisted by

medications vitamins iron

smoking drinking alcoholic beverage Condition at birth term /preterm/ post/term

good cry pinkish active

maternal illness: at month AOG weak cry cyanotic limp

Treatment
:
Birthweight:

Complications
Screening tests: result: :

NBS done? yes no result:

____B. Feeding history:

Breastfeeding and complimentary food (for < 2yo) Sample diet (for > 2yo) type and amount of food consumed

purely breastfed until Breakfast:

Breastfed >= 8x? yes no Lunch:

mixed feeding Dinner:

formula fed dilution Snacks:

Complimentary food started at what age?

Type of food:

___C. Developmental history:

Age 1-5 years old Age 6-9 years old Age 10-20 years old

Milestones

At what age did child Age School performance: H - ome

a. smiled at people

b. Hold up head

c. Roll over E - ducation

d. Sit unsupported

e. Stand alone Tanner staging:

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 f. Walk unsupported A - buse/ Activity

g. Talk

h. Toilet train

i. Feed him/herself D - rugs/Depression

j. Dress him/herself

S - afety

S - exuality

____D. Past illnesses:

Medical Illness Allergy to: Hospitalization

TB Asthma Food Surgery

Others Medicine Accidents

___VI. Immunization history:

BCG Hepa B OPV X dose/s

5-in-1 (DPT-Hib-Hepa B) X dose/s PCV X dose/s

Rotavirus X dose/s MMR X dose/s

Others Any reactions to vaccines?

___VII. Family History:

___VIII. Socioeconomic History:

___IX. Environmental History:

exposed to: cigarette smoke mosquitoes air pollution from vehicles/factories garbage

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PHYSICAL EXAMINATON

Weight (kg) Height/Length (cm) Head circumference (cm) for <3 yo Heart Rate RR Temperature BP

Systems
Describe Abnormal Findings:
(Write N=normal A=abnormal NA=not assessed)

General Survey

Skin

Head (including eyes, ears, nose,

mouth, and throat)

Neck (thyroid, lymph nodes)

Heart

Peripheral Vascular

Lungs

Abdominal

Genitalia

Back/Spine

Musculoskeletal

Neurologic

CLINICAL WORKING IMPRESSION

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