PEDIATRICS HISTORY

Date and Time of History: Relationship to Patient:

Source of History: Reliability:
IDENTIFYING DATA
Name: Age:
Gender: Birthday:
Religion: Place of Birth:
Nationality: Address:
Date of Admission:
Number of Hospital Admissions/Consultations:
CHIEF COMPLAINT
“Why was the patient brought to the hospital?”

HISTORY OF PRESENT ILLNESS

Onset

Location

“How long does it last?”

Duration “How often does it come?”

“How long does the pain last? (Constant or intermittent?)

Quality:
“How would you describe (insert symptom)? (dull/ sharp/ burning/ type)
Does the pain feel like cramping/squeezing?

Character
Quantity/Severity:
“How bad is it”
On a scale of 0 – 10, with 0 =no pain and 10 = worst pain you can imagine; how would you rate your pain?

What makes it worse?

Aggravating What makes it better?

/Relieving factors
Do activities like moving, walking, siting worsen the pain?

Does the pain spread /move /travel anywhere else?

Radiation
Frequency:
How often do you get this in a day (or week)?
How often have you had the pain?
How many times have you had the pain?
Timing
Progression:
Does the pain come and go?
Since it started, has it been getting better or worse?
In what way is it changing?

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 Setting:
What were you doing when this problem first started?

Medications (Generic and brand names) including actual dose (mg/kg/day or mg/kg/dose) and duration of treatment

Others Setting, Have you ever had anything like this before?
Frequency, Quality,
Timing, Severity,
Associated How does it interfere with your daily activities?
Symptoms

Do you have any other symptoms?

• Cough/Colds (Duration, Sputum quantity/Color)
• Fever (Continuous, Remittent, Intermittent)
• Vomiting (Amount, Color, Content)
• Diarrhea (Frequency, Amount, Pain)

PERSONAL HISTORY
PRENATAL, NATAL, NEONATAL HX included only in patients <2 years old. And if related to the illness for children >2 years old.
PRENATAL HISTORY
Age of mother during pregnancy: Were medications or herbs taken during pregnancy? If yes, what kind.
Birth order of px:
o Bleeding or spotting
o German measles (Rubella)
o Gestational diabetes Was a fertility treatment used for this pregnancy?
o High blood pressure
o Illness other than cold/flu
o Kidney disease
o Premature labor
o Threatened miscarriage
OB index:
o Duration of Pregnancy:
o Nutrition (diet, alcohol, cigarette, illegal drugs,):
o Weight gain:
o Infections(bleedings):
o Intake of drugs:
o Radiation exposure:
o Duration of gestation:
o Feeling about the pregnancy: (any stress/ problems)
NATAL HISTORY
o Term or premature or postmature:
o Manner of delivery: Breech, Caesarean, Forceps, Spontaneous vagina: Labor duration:
o if CS, indication (breech, cord coil, twins): Analgesia used:
o Hospital/Clinic:
o Congenital anomalies:
o Who attended:
o APGAR Score:
o Resuscitative effort:
o Birth weight:
o Complications encountered:

PEDIA
APGAR Score: ____

NEONATAL HISTORY
o Respiratory distress, Cyanosis, jaundice, anemia, convulsion or seizure, congenital anomalies, infection, hemorrhage
o Length of stay nursery/NICU:
o Problems with feeding:
o Mother healthy after delivery:
o Mother initial reaction to her baby:
o Pattern of crying, sleeping, urination, defecation:
o Separation of mother and infant (reasons):
FEEDING HISTORY
It is particularly important during first 2 years of life and in dealing with undernutrition and overnutrition
Infancy: (<2 y/o)
Type of feeding: (breastfed or bottle) if not breastfed, reason:
Frequency and Duration of feeding:
Formula (Brand and Dilution):
Type: Concentration: Amount (5 or 4 oz): Frequency of feeds:
Problem like regurgitation, colic, diarrhea:
Time and method of weaning:

Vitamins -type and when started

Complementary foods: Age solids foods started:

Type and amount of food given:
Consistency of food (Pureed, soft, lumpy, table foods) :
Frequency of feed:
Food intolerance:
Usual eating habits/preference (like and dislikes):
Childhood and Adolescents (2-20 y/o)
Appetite:
Type and amount of food eaten:
Feeding difficulties:
Food likes/dislikes:
Multivitamins and Iron supplements:
24-hour food recall:

DEVELOPMENT/BEHAVIOR HISTORY
Important during infancy and childhood and in dealing with delayed physical growth, psychomotor and intellectual retardation and behavioral disturbances.

At present, the child is playful and active. Developmental milestones are _____________ with age. Patient sleeps ______________ in
the evening wakes up at __________ in the morning. Non/Toilet trained, interacts with family and peers with/without discipline
problems.

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 Developmental milestone:
At what age did child: Age:
o Held head ___________
o Roll over
o Sat with support and alone
o Stand with support and alone
Infants and Young o Dental eruption
Children o Walk
(Birth-5y/o) o Talk
o Toilet train
o Feed him/herself
o Dress him/herself
Other behavioral problems:
o Urinary continence, toilet training started and completed
o Tantrums, phobias, pica, night terrors, sleep disturbances
Inquire about school performance, adjustments, academic achievements, school’s concerns
_______________________________________________________________________________
Sexual development using Tanner’s Maturity Rating: _______
Stage Pubic Hair Breasts
1 None Preadolescent
Sparse, lightly pigmented Straight, Medial border of Breast and papilla as small mound, Areolar diameter
2
labia increased
3 Darker, Beginning to curl, Increased amount Breast and areola enlarged, no contour separation
4 Coarse, curly, Abundant but amount less than in adult Areola and papilla form secondary mound
Middle Childhood
Adult feminine triangle spread to the medial surface Mature, nipple projects, Areola part of general breast
(6-11 years) 5
of thighs contour
Stage Pubic Hair Penis Testes
1 None Preadolescent Preadolescent
Enlarged scrotum, Pink texture
2 Scanty, long, Slightly pigmented Slight enlargement
altered
3 Darker, Starts to curl, Small amount Longer Larger
Resembles adult but less in quantity, Coarse Larger, Glans and breadth Larger, Dark scrotum
4
and curly increases in size
Adult distribution, Spread to the medial Adult
5 Adult
surface of thighs

HEADS/S/FIRST
Home- space, privacy frequent geographic moves, neighborhood
Education/School- school changes, teacher’s report, learning disabilities
Abuse- physical, sexual, emotional, verbal, parental discipline
Drugs- tobacco, alcohol, marijuana, inhalants
Safety- seat belt, helmets, sports safety measures, hazardous activities
Adolescence Sexuality/Sexual identity - reproductive health (use of contraceptives, STDs, pregnancy)
(10-20 years) Family/Friends- family constellation, married/separated/ divorce/; peer configuration
Image- height and weight perception, body musculature and physique, appearance (dress, jewelry, tattoos,
body piercing)
Recreation- sleep, exercise, organized or unstructured sports, recreational activities (TV, video games, computer
games, internet), church or community activities
Spirituality and Connectedness-hope or security for future, religion, personal spirituality and practices
Threats and Violence- self harm or harm to others, running away, fights, arrest, fight in school
Self-breast Examination
Female patient
Sexual development:

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 o Birth Control:
o Number of sexual partners: Gender of sexual partners:
o Sexual function: Sexually Transmitted Infection:
Menstrual History
o Menarche: Days of cycle:
o Regularity: Duration of menses:
o Flow: Pads per day:
o LMP:

PAST MEDICAL HISTORY

Has the child had:
o Blood: anemia (iron deficiency, Sickle Cell, Thalassemia)
o Blood transfusions
o Chicken pox (Varicella)
o Contusions
o Convulsions
Childhood Illness
o Fractures
o German Measles (Rubella) (Tigdas hangin)
o Measles (Rubeola) (Tigdas)
o Meningitis
o Mumps (Beki)
o Asthma
Hospitalizations/Surgery

Accidents/Injuries
Is your child currently taking any medications, vitamins or herbs?
Medications
Medication Strength/Dose How Often?
Allergies Eczema, Food and Drug sensitives

IMMUNIZATION HISTORY
Place (health center, doctor’s clinic)
Yes (Age) No Adverse reactions
BCG Vaccine
DPT (Diphtheria, Tetanus, and Pertussis) Vaccine
OPV Vaccine
Hepa B Vaccine
MMR Vaccine
Influenza
Hemophilus influenza type B (Hib) vaccine
Pneumococcal conjugate vaccine
Rotavirus
Hepatitis A
Typhoid Vaccine
Any recent immunizations? ___________________
COVID vaccines and Booster? ___________________

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 FAMILY HISTORY
FATHER Age: Mother Age:
[ ] Living [ ] Living
PARENTS [ ] Deceased [ ] Deceased
Occupation: Occupation:
Health Condition: Health Condition:
Medications: Medications:
Age: Age:
SIBLINGS: [ ] Living [ ] Living
(#of brothers: ____) [ ] Deceased [ ] Deceased
(# of sisters:______) Health Condition: Health Condition:
Medications: Medications:

Health status of Age: Age:

immediate family [ ] Living [ ] Living
members [ ] Deceased [ ] Deceased
Health Condition: Health Condition:
Medications: Medications:
Paternal grandfather’s Age: Paternal grandmother’s age:
[ ] Living [ ] Living
GRANDPARENTS [ ] Deceased [ ] Deceased
Health Condition: Health Condition:
Medications: Medications:
Maternal grandfather’s age: Maternal grandmother’s age:
GRANDPARENTS [ ] Living [ ] Living
[ ] Deceased [ ] Deceased
Health condition: Health condition:
Familial illness or Any member of the family with similar symptoms?
anomalies
TB, DM, cancer, epilepsy, RF, allergy, Asthma
Hereditary Hematologic disorders, Mental retardation, Congenital defects

SOCIOECONOMIC / ENVIRONMENTAL HISTORY

Living circumstances: Type of House:
No. of bedrooms:
No of CR: Type of CR:
Household members:
Lighting: Ventilation:
Source of water: Drinking water:
Economic circumstances: Member of family who works:
Source of funds:
Environmental Smoking: (type, duration, frequency) (smokers in the family)
circumstances: Alcohol: (type, duration, no. of bottles, frequency)
Drugs: (type, duration, frequency)
Exercise: (type, duration, frequency)
Garbage disposal:
Cleaning:
Pets:
Environmental exposure: (dust, pollutants)
Significant life event (death, divorce, financial hardships):
Leisure Activities:

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 School Affiliations:
ADLs:
Sleep pattern:
Alternative Health Care Practices:

REVIEW OF SYSTEMS
A search for symptoms referable to organs or systems not covered by the history of the present illness during the course of the present illness. Ask only symptoms applicable
to the age of the patient.
General Skin Head
[ ] Significant weight change [ ] Rash [ ] Headache
[ ] Generalized body weakness [ ] Itching [ ] Trauma
[ ] Fatigue [ ] Excessive dryness or sweating [ ] Dizziness
[ ] Fever [ ] Cyanosis [ ] Vertigo
[ ] Chills [ ] Pallor
[ ] Night sweats [ ] Jaundice
[ ] Activity level (Irritability, lethargy) [ ] Erythema
[ ] Appetite [ ] Hair loss
[ ] Delay in growth
Eyes Ears Nose
[ ] Pain [ ] Earache [ ] Changes in smell
[ ] Blurring of vision [ ] Deafness [ ] Dryness
[ ] Double vision [ ] Tinnitus [ ] Sneezing
[ ] Lacrimation [ ] Ear discharge [ ] Nose bleeding
[ ] Photophobia [ ] Nasal obstruction
[ ] Use of corrective lenses [ ] Nasal discharge
[ ] Pain over paranasal sinuses
Mouth and Throat Neck Breast
[ ] Toothache [ ] Pain [ ] Pain
[ ] Gum bleeding [ ] Limitation of movement [ ] Lumps
[ ] Disturbance in taste [ ] Swollen glands [ ] Nipple discharge
[ ] Sore throat [ ] Lumps
[ ] Hoarseness [ ] Goiter
[ ] Ulcers
Respiratory Cardiovascular Gastrointestinal
[ ] Pleuritic chest pain [ ] Chest pains/discomfort [ ] Abdominal pain
[ ] Cough [ ] Palpitations [ ] Nausea
[ ] Sputum production [ ] Undue fatigue [ ] Vomiting
Color: ______ [ ] Syncope [ ] Dysphagia
Amount: ______ [ ] Orthopnea [ ] Diarrhea
[ ] Hemoptysis No. of pillows: [ ] Indigestion
[ ] Cyanosis [ ] Constipation
[ ] Wheezing [ ] Fecal incontinence
[ ] Dyspnea [ ] Hemorrhoids
[ ] Melena
[ ] Hematochezia
[ ] Regurgitation
[ ] Passage of worms
Genitourinary Endocrine Nervous/behavioral
[ ] Dysuria [ ] Intolerance to heat or cold [ ] Loss of consciousness
[ ] Urinary frequency [ ] Polydipsia [ ] Focal weakness
[ ] Urgency [ ] Polyuria [ ] Paresthesia
[ ] Hematuria [ ] Polyphagia [ ] Paralysis

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[ ] Urinary Incontinence
[ ] Genital pruritus
[ ] Urethral discharge
[ ] Vaginal discharge
[ ] Dysmenorrhea
[ ]Testicular pain
[ ] Dyspareunia
Musculoskeletal
[ ] Edema
[ ] Swelling of joints
[ ] Stiffness
[ ] Numbness
[ ] Intermittent claudication
[ ] Limitation of movement
[ ] Hair change [ ] Speech disorder
[ ] Loss of memory
[ ] Confusion
Hematopoietic Psychiatric
[ ] Excessive bleeding [ ] Seizures
[ ] Easy bruising [ ] Sleep disorder
[ ] Anemia [ ] Coordination problem
[ ] Sensory disturbance
[ ] Motor problem
[ ] Tremors
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 PHYSICAL EXAMINATION
Patient is weak looking, awake, coherent, irritable, no signs and symptoms of dehydration, ambulatory, well
developed, poorly nourished, and not in cardiopulmonary distress.
o Mental state and sensorium
GENERAL
o Presence of cardiopulmonary distress or not
APPEARANCE/
o Ambulatory/ bedridden
SURVEY
o Nutritional state (Well, Under, or Over nourished)
o State of hydration
o Ill looking
VITAL SIGNS
o Temperature: Respiratory rate:
o Pulse Rate: O2 Saturation:
o BP (>3years old):
ANTHROPOMETRIC DATA
o Weight (kg): Head Circumference (cm) (<3 years old):
o Height: Chest circumference (cm):
o BMI (kg/m2): Abdominal circumference (cm):
o Arm span & U/L segment – for children with growth disorders:
[ ] Pallor, [ ] jaundice, [ ] cyanosis, [ ] rashes, [ ] scars, [ ] petechiae, [ ] pigmentation, ____________ to touch,
SKIN
skin turgor: [ ] good, [ ] poor
Head: A/Symmetry, [ ] scars, [ ] lesions, [ ] gross deformities, ________ hair distribution, non/sunken fontanels,
[ ] tenderness, [ ] swelling, [ ] Face deformities/lumps/bumps.

Eyes: Non/Sunken eyeballs, [ ] periorbital edema , an/icteric sclera, pale/pink palpebral conjunctiva,
[ ] pupils ERTL, [ ] discharge, [ ] Red orange reflex, [ ] EOM intact, [ ] drooping lids, [ ] crusting of eyelashes,
[ ] redness/opacities/swelling. [ ] Bitot’s spots, [ ] Subconjunctival hemorrhages
[ ] Narrow palpebral fissure (ptosis), [ ] Wide palpebral fissure (Exophthalmos), [ ] Lids slanted upwards (Down’s
syndrome), [ ] Dennie -Morgan folds (Atopy/AR)

Ears: Ab/normally set ears, [ ] discharges, [ ] impacted cerumen, ___________ tympanic membrane, [ ]
erythema/bulging, hearing acuity on both ears ___________

HEENT Nose: [ ] discharges, [ ] Congestion, [ ] alar flaring, External structures symmetry: __________ External
structures deformities: __________, Turbinate appearance:______________ [ ] pink/moist,
Position of Septum: ___________
Mouth: [ ] Moist Mucous membranes, Lips ( [ ] fissures, [ ] cleft, Color: [ ] pale, [ ] cyanotic, [ ] cherry red)
Teeth: number & position ________, [ ] caries, [ ] malalignment
Gums: [ ] Bleeding, [ ] Ulcers,
Tongue: [ ] Symmetry , [ ] Color: [ ] Strawberry tongue, [ ] cyanosis, [ ] Ankyloglossia (tongue tied),
[ ] Macroglossia, [ ] Ulcers.
[ ] Epstein pearls, [ ] Ranula, [ ] Mucocele

Throat: Tonsils size & appearance: __________ [ ] inflammation, Voice ( [ ] hoarseness, [ ] stridor, [ ] grunting),
Pharynx : [ ] erythema/ulcerations, [ ] Thrush, [ ] Koplik spots. Palate: [ ] Symmetry, [ ] Vesicles/ulcers
Grossly non/swollen. [ ] tracheal deviation. With/without decrease in ROM. [ ] Lymphadenopathy, [ ] goiter or
NECK
masses.
BREAST [ ] Mass, [ ] Redness/Lesion, [ ] Nipple Discharge, [ ] Palpable Mass, Tanner Stage: ___________
Inspection
THORAX/LUNGS
RR: __________ [ ] Symmetry of chest AP diameter : __________

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 [ ] Round/Barrel chest, [ ] Shielded shaped, [ ] pectus excavatum, [ ] Pigeon chest, [ ] Rachitic Rosary, [ ]
Harrison’s Groove
Chest Retractions: [ ] Subcostal, [ ] Intercostal, [ ] Supraclavicular
[ ] Mass, bulges, and scars on both anterior and posterior chest
[ ] Lagging of respiratory movement
[ ] Irregular and asymmetrical breathing

Palpation
Trachea deviation: [ ] Midline
Chest expansion: [ ] Normal/Symmetrical, [ ] Bilateral reduction, [ ] Unilateral reduction
Tactile fremitus: [ ] Increase, [ ] Decrease, [ ] Absent

Percussion
[ ] Resonant , [ ] Dullness, [ ] Hyper resonant

Auscultation
Breath sounds: [ ] Vesicular , [ ] Bronchial, [ ] Bronchovesicular
[ ] Crackles : [ ] Fine, [ ] Coarse
[ ] Wheezes, [ ] Rhonchi, [ ] Bronchial/Tubular BS, [ ] Pleural friction rub, [ ] Stridor, [ ] Grunting

Altered voice sounds in Lobar Pneumonia:

[ ] Bronchophony, [ ] Egophony (Normal “ee” heard as “ay”), [ ] Whispered pectoriloquy
Inspection
JVP (>8 years old, Normal: no greater than 3 cm): ____
Precordium: [ ] Adynamic, [ ] Dynamic, [ ] Hyperdynamic
[ ] Precordial bulge, [ ] Jugular venous distension, [ ] visible pulsations

Palpation:
Apex beat: [ ] 4th ICS MCL (< 7y/o), [ ] 5th ICS MCL
[ ] Displaced laterally & inferiorly, [ ] Displaced to the right
[ ] Thrills, [ ] Parasternal Heaves, [ ]Substernal thrust
Pulses: [ ] Decrease pulses in extremities, [ ] Bounding, [ ] Radial femoral delay
Capillary Refill: [ ] < 2- 3 seconds, [ ] > 2-3 secs

Auscultation:
CARDIOVASCULAR
Murmurs:
Systolic: ( [ ] Midsystolic, [ ] Late systolic, [ ] Pansystolic)
Diastolic: ( [ ] Early diastolic, [ ] Mid diastolic)
[ ] Presystolic murmur, [ ] Continuous murmur

Grade of Intensity of murmurs:

[ ] 1: Barely audible, [ ] 2: Medium intensity, [ ] 3: Loud but no thrill, [ ] 4: Loud with thrill,
[ ] 5: Loud & audible with stet barely on chest, [ ] 6: Audible with stet off chest

Auscultation
S1: ___________
S2: ___________
[ ] S2 splitting
Extra Heart sound: [ ] S3, [ ] S4

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 [ ] Scoliosis, [ ] Lordosis, [ ] Kyphosis, [ ] tenderness, [ ] rigidity, [ ] spina bifida, [ ] sacral dimple, [ ] hair tuft,
SPINE
[ ] Mongolian spots
Inspection
[ ] scars, [ ] striae, [ ] hernias, [ ] dilated veins, [ ] Lesions/rashes , [ ] discolorations, [ ] Cullen’s sign, (ecchymosis
periumbilical), [ ] Grey turner sign (ecchymosis of flanks)
[ ] Visible pulsations, [ ] Visible pulsations, [ ] Visible peristalsis

Contour: [ ] flat, [ ] scaphoid, [ ] globular/protuberant, [ ] rounded, [ ] distended

(Infants: usually have protuberant and soft abdomens, Child: scaphoid/slightly rounded)
Symmetry: __________
Umbilicus: [ ] flat, [ ] everted) , [ ] infection, [ ] hernias)
Auscultation
Bowel sounds: [ ] absent (not heard after 3-5 mins), [ ] hypoactive, [ ] hyperactive, [ ] borborygmi
Bruits: [ ] Renal Arteries, [ ] Iliac Arteries, [ ] Aorta
Friction rubs: [ ] R/LUQ
Percussion
Tympanic: (Hollow viscous) ___________
Dullness: (organs, fluid, feces) _______________
Hyper resonant: (Air, lungs) _________
ABDOMEN Abdomen distension: [ ] Air, [ ] Fluid
Fluid wave/ Shifting dullness (Ascites): ______

Liver span: _____________

[ ] Increased liver dullness ( Hepatomegaly)
[ ] Decrease liver dullness ( Liver cirrhosis)
[ ] Displaced (COPD/emphysema)

Palpation:
[ ] Direct tenderness, [ ] Rebound/ Indirect tenderness
[ ] Board like rigidity

Liver size: ___________ (Infants and young children Liver normally palpable; length along RMCL 0-6 mos. 3.0-3.5 cm
below right subcostal margin) 6 mos- 4y 0-3 cm
Spleen: [ ] (Not palpable unless enlarged 2-3 times its size) 4-10 y <2 cm
Aorta: [ ] >3cm pulsatile mass >10 y <1 cm
Kidney: [ ] (palpable thin/malnourished, The kidneys are not palpable in most normal patients )
[ ] CVA tenderness (done in older children/adolescents), [ ] Psoas sign, [ ] Obturator sign, [ ] Rovsing's sign,
[ ] Murphy's sign
Tanner Stage: ______
Male:
[ ] circumcised, [ ] hypospadias, [ ] epispadias, [ ] phimosis, [ ] adherent foreskin, [ ] cryptorchidism, [ ]
GENITALIA hydrocele, [ ] hernia
Female:
Vagina: [ ] imperforate, [ ] discharge, [ ] adhesions), [ ] hypertrophy of clitoris, [ ] lacerations
Hymen: [ ] Normal, [ ] Imperforate, [ ] Microperforate, [ ] Cribriform, [ ] Septate
[ ] Fissures, [ ] hemorrhoids, [ ] prolapse, [ ] abnormal masses, [ ] imperforate anus, [ ] tenderness, [ ] presence
RECTAL
of worms
General: [ ] Deformity, [ ] Atrophy, [ ] Asymmetry, [ ] bowlegs , [ ] knock-knees , [ ] paralysis, [ ] edema, [ ]
EXTREMITIES coldness.
Joints: [ ] Swelling, [ ] redness, [ ] pain, [ ] limitation, [ ] tenderness, motion

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 Hands and feet: [ ] Extra digits, [ ] clubbing, [ ] simian lines, [ ] curvature of little finger, [ ] deformity of nails, [ ]
splinter hemorrhages, [ ] abnormalities of feet, [ ] syndactyly, [ ] polydactyly , [ ] genu varum, [ ] genu
valgummm, [ ] clubfoot

Hips (Infants): [ ] Ortolani’s, [ ] Barlow’s signs

Peripheral Vessels: [ ] Presence, [ ] absence or diminution of arterial pulses.

Level of consciousness:
[ ] Awake, coherent, [ ] Drowsy, [ ] lethargy, [ ] irritability, [ ] Obtundation, [ ] Stupor , [ ] Coma
GCS : ______
Speech: [ ] Delayed, [ ] Slurred , [ ] Monotonous, [ ] Staccato/Choppy

Cranial Nerves:
CN 1 Olfactory: [ ] Anosmia, [ ] Correctly identified by smell in both nostrils

CN 2 Optic: [ ] Visual fields full to confrontation, [ ] Optic discs normal bilaterally, [ ] Corrected visual acuity, [ ]
Blindness, [ ] Papilledema

CN 3 Oculomotor, CN 4 Trochlear, CN 6 Abducens: [ ] Eye movements full and coordinated, [ ] No pathological

nystagmus, [ ] Pupils prompt reaction to light and convergence, [ ] ptosis, [ ] mydriasis, [ ] nystagmus

CN 5 Trigeminal: [ ] Sensation in the face intact, [ ] Complete paralysis of the 5th nerve [ ] Corneal reflex
symmetrically elicitable, [ ] Diminished or absent corneal reflex , [ ] Masseter strong bilaterally

CN 7 Facial: [ ] Symmetry of face, [ ] Asymmetry/ facial droop, [ ] Facial expression normal (both voluntary
and involuntary movements). [ ] Facial muscle strength is normal and equal bilaterally, [ ] Bell’s palsy, [ ] Central
facial palsy, [ ] Loss of taste anterior 2/3

NEUROLOGICAL CN 8 Acoustic: [ ] Hearing normal bilaterally, [ ] Weber not lateralized, [ ] Conductive hearing loss, [ ]
Sensorineural hearing loss

CN 9 Glossopharyngeal, CN 10 Vagus : [ ] Ability to swallow and speak clearly, [ ] Uvula and tongue in midline
position, [ ] Palate and uvula elevate symmetrically, with intact gag reflex. [ ] Voice is normal.
[ ] Loss of taste in then posterior 3rd of the tongue, [ ] Loss or decreased gag reflex, [ ] Deviation of the uvula to
the normal side.

CN 11 Accessory: [ ] Trapezius , [ ] Sternocleidomastoid muscles strength full and symmetrical.

[ ] Asymmetry in shoulder movement, [ ] Asymmetry in bulk (atrophy), and contraction of the
sternocleidomastoid muscles.

CN 12 Hypoglossal: [ ] Tongue protrudes midline and moves symmetrically. [ ] Tongue deviates toward side of
injury

Cerebellar Function:
[ ] Rapidly alternating pronation and supination of hands, [ ] Finger-to-nose and heel-to-shin test normal
bilaterally. [ ] Balances with eyes closed (Romberg). [ ] Rapid alternating movements normal.
[ ] Coordination is intact as measured by heel walk and toe walk.
[ ] tremor, [ ] ataxia, [ ] posture, [ ] abnormalities of muscle tone.
[ ] Dysrhythmia, [ ] Dysdiadochokinesia, [ ] Dysarthria

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Gait
[ ] Gait is steady with a normal base.
[ ] Spastic gait, [ ] Hemiparetic gait, [ ] Cerebellar ataxia, [ ] Sensory ataxia, [ ] Myopathic ataxia

Motor System:
[ ] Good muscle tone, [ ] Spasticity, [ ] Rigidity, [ ] Clonus
[ ] Athetosis, [ ] Ballismus, [ ] Chorea, [ ] Dystonia, [ ] Tremor

Muscle strength at the deltoid, biceps, triceps, quadriceps, and hamstrings: _______
[ ] 0: No contraction, [ ] 1 : Flicker or trace of contraction, [ ] 2: Active movement, with gravity eliminated , [ ]
3: Active movement against gravity ,[ ] 4: Active movement against gravity and resistance , [ ] 5: Normal power
[ ] myotonic contraction, [ ] fasciculations, [ ] tremor, [ ] resistance to passive movement, [ ] involuntary
movement.

Sensory System:
[ ] Sensation is intact bilaterally to pain and light touch. [ ] Two-point discrimination is intact.
[ ] Astereognosis, [ ] Agraphesthesia

Grade Description
Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are ___ 0 Absent
bilaterally. 1+ or + Hypoactive
1. Deep reflexes - Biceps, brachioradialis, triceps, patellar, Achilles; rapidity and 2+ or ++ Normal
strength of contraction and relaxation. 3+ or +++ Hyperactive
(not usually tested in children under 5 years of age ) without clonus
4+ or ++++ Hyperactive with
2. Superficial reflexes - Abdominals, cremasteric, plantar, gluteal. clonus
3. Pathologic reflexes - Babinski, Chaddock, Oppenheim, Gordon

Newborn and infant reflexes

[ ] Rooting, [ ] Sucking, [ ] Tonic neck, [ ] Palmar Grasp , [ ] Stepping, [ ]Moro, [ ] Plantar grasp, [ ] Babinski, [ ]
Landau

Meningeal signs: [ ] Brudzinski , [ ] Kernig signs

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