Informant: mother/ father/ grandmother/ etc.

A ___________ (age) , hindu/ muslim/ (religion) male/female (sex) child belonging to ___________
socioeconomic class residing at ____________ (address) has come to ___________ (hospital) with
the chief complains of…….

Chief complains:

Write the chief complains in chronological order of appearance…..

Cough: _____ days

Cold: _____ days

Fever: _____ days ………..

Origin/ duration/ progress:

Patient was relatively asymptomatic before _____ days then he/ she developed……. (Symptoms)

A) Cough: ___________ days

More at night/ day/ throughout the day; character: paroxysmal cough/ barking; Dry/ productive;
Colour of sputum: white/ yellow/green; Post tussive vomiting: yes/no; more in the morning/ night;
Relieved by; is cough of sudden onset

A) Fever: No. of days: ____________; High grade/ moderate grade/ low grade; Continuous/
intermittent/ remittent; Associated with chills and rigors or not; Diurnal variation if any;
Relieved by: ____________
B) Cold: duration; Nasal block; Watery/ mucoid / yellowish green discharge
C) Breathlessness: yes/no; grade of breathlessness
D) Vomiting: regurgitation of feeds (infants d/t aerophagy); duration; frequency; associated
nausea; projectile/ non- projectile; presence of blood/ bile/ faecal matter (intestinal
obstruction); aggravating factors; relation to food; associated symptoms (fever, headache,
altered sensorium: CNS infection) (abdominal distension & constipation: intestinal
obstruction) (associated diarrhoea: acute gastroenteritis) ;
E) Increased frequency of stools: duration; passing stool after each feeds esp. newborns
(exaggerated gastro colic reflex); frequency; consistency; colour; presence of mucous/
blood/ pus in stools; abdominal colic present or not
F) Pain in abdomen: duration; frequency; timing; site (localised/diffuse) severity; type of pain
(burning/ piercing/ boring/ colicky); aggravating & relieving factors
G) Altered level of consciousness: altered sleep pattern/ drowsy/ stupor/ delirium/ comatose

Past history: no h/o major illness in past/ h/o any surgery/ tuberculosis/ blood transfusion/
childhood viral exanthem (measles/ varicella); h/o delayed cry at birth/ convulsions; h/o prolonged
medication (for epilepsy/ iron chelators/ insulin); any other/ NAD

Family history: father/ mother; their occupations; education status

Pedigree chart

No. of family members: ____________

Per capita income ____________ (find out the socio economic status from Kuppuswamy/ Prasad
classification)

Siblings: live ____________/ abortions ____________/ death ____________

Any disease to siblings: ____________________________________

H/o tuberculosis/ blood transfusion/ any other disease to any family member

Lives in kutcha house/ pucca house; proper water supply, drainage & sanitation facility; ventilation
available/ not; (disease like tuberculosis is common due to overcrowding)

Birth history: full term/ preterm/ post term

Vaginal delivered/ LSCS delivered/ instrumental delivery (FORCEPS/ VACCUUM)

Birth weight: _____________ kg; AGA/ SGA/ LGA

Any post natal complications; Cried soon after birth: yes/ no; Any h/o meconium aspiration: yes/ no
H/o NICU admission: yes/ no; Neonatal jaundice: yes/no; Exchange transfusion done: yes/ no

H/o antenatal TT taken by mother: yes/ no. No. of doses: 1 / 2; H/o antenatal iron/ FA taken by
mother: yes/ no

Immunization History: BCG: ___________ Scar +/-

OPV: 1 /2/ 3; DPT: 1 /2/ 3; Hepatitis B: 1 /2/ 3; Measles/Rubella; TT/DT/ DPT (10 years); PPI:

Boosters: DPT: 1 /2 OPV: 1 /2 MR vaccine

Diet History: On BF: YES/ NO; Full family diet: Yes/No; anything specific:

Calorie count/ protein count; expected for weight

Development History: gross motor/ fine matter/ social- personal/ language

Studies in Std.______ Good/fair/poor at studies

Simple mathematical calculations for children above 5 years

General examination:

I have examined the patient in proper light and with proper exposure. Patient was conscious/ co-
operative and well oriented to time, place and person. / Lying comfortably on bed. / Restless,
anxious, irritable.

Anthropometry:

Weight: ___________ kgs

Height/ length: ___________ cms

Head circumference: ___________ cms

Chest circumference: ___________ cms

Mid arm circumference: ___________ cms

Upper segment/ lower segment ratio: --------

Vital parameters:

Temperature: ____________°F

(Usually axilla in infants/older children axillary temperature/ rectal temperature in malnourished/

very ill children)

Rectal temperature > oral temperature > axillary temperature by 1°F

Pulse/ heart rate: _____/min, bilaterally symmetrical, rate, rhythm, volume, force. Pulse rate Varies
with the age of the child.

Respiratory rate: _______/ min, abdominal/ abdomino- thoracic/ thoracic

Breathing is abdominal in infants/ abdomino- thoracic in young children & thoracic in older
children and adolescents.

Respiratory rate varies with age.

Blood pressure: ______________ mm of Hg

Compare them with expected values for that age.

Head to toe examination:

Shape of head, bossing,

Anterior fontanel

Hair: colour, texture, sparse, easily pluckable

Abnormalities of eyes, ears, nose, mouth and chin

Oral cavity: abnormalities, dentition

Pallor/ Cyanosis/ clubbing/ lymphadenopathy/ edema

Examination of bones/ joints/ spine

Gait

Signs of vitamin deficiency

Hernia orifices

Systemic examination

Provisional diagnosis: