Name & RN

Age

Informer

Chief complaint

HOPI

Site

Onset (when,
acute/gradual)

Characteristic

Radiation

Alleviating
factors

Timing

Exacerbating
factors

Severity

Progression

Intermittent /
continuous
Paeds systemic review
General
Fever Behavior

Activity / apathy/ Rashes

alertness

Growth Weight

Cardiorespiratory
Cough Dyspnea

Noisy breathing cyanosis

(stridor, croup,
wheeze)

Gastrointestinal
Vomiting Abd pain

Diarrhea Nausea
/constipation

Genitourinary
Wetting Nappies

Toilet trained Dysuria

Frequency Hematuria

Neuromuscular
Seizure Headaches

Abnormal Joint / muscle

movements pain

ENT
Sore throat Snoring

Noisy breathing Ear ache

Birth
Pregnancy problems

Maternal illness

Maternal drug use

Birth history

Place of birth

Gestation
(37-40weeks) & birth
weight

Mode of delivery

Birth complications
(eg resuscitation
required, birth injury,
malformation)

Neonatal problem (
jaundice, fits, fever,
bleeding, feeding
problem)

Feeding
Diet and appetite

Breast/ bottle milk (<12

months) - which formula?
How much (150-200ml/day
or breast feed every 2
hours)

Weaning (6-12months)
Start with pureed jars→
mashed up food → solid

Solis meals/ cow milks

(>12months)
Toilet training (2-4 year,
dry day by day 2 years, dry
by night 3-4 years)

Frequency wet nappies

(usually 5 soaking wet
nappies/ day and 3 yellow
stools)

Development

Any concerns

School progress &

attendance

Past medical history

Any known
illnesses?

Previous
hospitalization

Surgery

Allergy (drug,
foods, others)
Drug history

Immunization - up
to date/ reactions

Current
medications (
dose, route,
compliance)

Relevant recent
medication eg
course of steroid
for asthma

Family history

Anything relevant
to chief complaint

Anyone else ill

Social history

Family unit (parents,

sibs, who live at
home)

Anyone smoke in
the fam?

Housing situation

Social service
involvement

Playgroup (2-5
years), nursery
school (3-4y),
school (5-16 y)-
performing well?

Others (hobbies,
travel, pets)

Ideas , concern, expectations

How does illness
affect family?

Have the symptoms

kept the child from
attending
nursery/school?

parents/child’s
concern, beliefs,
hopes etc

These have been taken from www.OSCEstop.com (2013).