University of Northern Philippines

Tamag, Vigan City, Ilocos Sur

College of Medicine

History Taking and Physical Examination

(Pediatrics) Version 3.0
Created by Stephen A. Ujano
*For Individual Use Only

DATE & TIME. _________________

I. GENERAL DATA.
Name: _________________________
Sex: [M] [F]
Age: __________
Marital Status: [S] [M] Others: __________________
Address: ________________________________________________________________________________
Religion: ________________________________________________________________________________
Race /Ethnicity/Citizenship: _________________________________________________________________
Number and Date of Hospital Admissions: _____________________________________
_____________________________________
Source of Information: _____________________________________________________
Referral: ________________________________________________________________
Reliability: _____________
II. CHIEF COMPLAINT. _____________________________
III. HISTORY OF PRESENT ILLNESS.

(NOTE!) - State in chronological order from the start of the illness.

- Use specific number of hours or days; for chronic illness, state date and age of onset.
- If newborn, and/or present problem is related to prenatal & perinatal period, include maternal and birth history.
- Elaborate OPQRST (onset, precipitating factors, quality; localization; duration; frequency, relieving/aggravating factors, associated signs and symptoms
& its OPQRST); indicate mg/kg dose for medications and specific dilution for milk formula.
- Include Past History if relevant to present illness (e.g. previously diagnosed with a disease related to current complaint/illness)

IV. PAST

Age

Complications

HISTORY.

A. Childhood

Illnesses:
1. Measles
2.
3.
4.
5.
6.
7.
8. Scarlet fever
9. Others:
_____________________

Mumps
Rubella
Poliomyelitis
Varicella
Pertussis
Rheumatic fever

B. Medical: (tuberculosis, hepatitis, asthma, or allergies, injuries/accidents, hospitalizations [date; place; diagnosis; treatment])

C. Surgical: (date; place; indication; type of operation)

D. Obstetric/Gynecologic: (include caesarian sections and reason; pregnancy complications)

OB History: G[ ] P[ ] T[ ] P[ ] A[ ] L[ ] M[ ]
Age of Menarche: _______________

Menstrual History: ____________________________

LMP: ______________

E. Psychiatric: (Illness, time frame, diagnosis, hospitalizations, treatments)

V. IMMUNIZATION HISTORY AND TUBERCULIN TEST.

Immunization
1
BCG
Hepatitis B
OPV
DPT
MMR
Tetanus Toxoid
Pentavalent
DTaP <7y/o/TDap 7y/o

Varicella
Pneumococcal
Influenza
Rotavirus
Others:

Tuberculin Test:
Other Screening Tests:

st

nd

Age Given/Date
3rd
4th

Place
th

5 / Boosters

Untoward Reactions

VI. FAMILY HISTORY.

Member

Age

Occupation

Health Status

Age of Death

Cause of Death

Paternal Grandmother
Paternal Grandfather
Father:
Maternal Grandmother
Maternal Grandfather
Mother:
Siblings:

Familial Illnesses: (tuberculosis, DM, syphilis, cancer, epilepsy, RHF, mental/psychiatric, congetinal)

(NOTE!) Make a genogram of the family if relevant and note for consanguinity.

VII. PERSONAL HISTORY.

(NOTE!) For <2 y/o patient or >2 y/o with relation to current illness.

A. Gestational History:

(NOTE!) Age of mother during pregnancy; parity; health, nutrition; infection; drug/alcohol use; radiation exposure; duration of
gestation if pertinent especially in infants.

B. Birth History:

(NOTE!) Term, premature or postmature; manner of deliver and reason if C-section; attending persons; birthweight if pertinent especially in

infants.

C. Neonatal History: (NOTE!) APGAR Score; spontaneous respiration or required resuscitation; cyanosis; pallor; cry; jaundice )include onset); hemorrhage;
convulsions; respiratory of feeding difficulties; congenital birth injury if pertinent especially in infants)

D. Feeding History
Infancy (<2 y/o):
A.

Type of Feeding: Breastfeeding; exclusive or mixed; frequency; duration per breast; if not breast feeding: give reason, formula used & dilution,
amount per day, bottle or cup feeding; indicate specific dilution for milk formula

B.

Complementary Foods: Age introduced; initial and subsequent foods introduced; consistency of food; frequency of feeding/day

C.

Usual Food Intake: Breakfast; lunch; dinner; snacks; assess five basic food groups; preferred foods

D. Compute for Caloric Intake; Comparison with RENI or food intake to Food Guide Pyramid
(See reference for computation; See Appendix A for the RENI)
E. Food Intolerance:
F. Multivitamins/Supplements: Dose; frequency

G. Caregiver: Mother; household help, grandparents; siblings

Childhood and Adolescents (2-20 y/o):

(NOTE!) Omit early feeding history unless it is pertinent to present illness.

A. Describe Appetite:
B. Usual Food Intake: Meals and snacks per day; amount

C. Assess Five Basic Food Groups:

D. Compute for Caloric Intake; Comparison with RENI or food intake to Food Guide Pyramid
(See reference for computation; See Appendix A for the RENI)
E. Multivitamins/Supplements:

Dose; frequency

E. Developmental / Behavioral History .

A. Infancy (<1 y/o):

(NOTE!) You can use DENVER II for <1 y/o as a guide during the interview

B. Young Children (1-5 y/o):

I. Modified Developmental Checklist
(See reference)
II. Dental Eruptions: Age of first tooth eruption, first tooth to erupt

III. Other behavioral problems including the following:

urinary incontinence, day/night; toilet training, started and completed;

temper tantrums; head banging; phobias, pica, night terrors, sleep disturbances.

(NOTE!) If there are indications of developmental delay, detailed test should be done e.g. Denver Developmental Screening Test.

C. Middle Childhood (6-11 y/o):

I. School Performance: Class standing; absences and reason; achievements
FEMALE BREAST
MALE GENITALIA
STAGE:
Description:
STAGE:
Description:

FEMALE GENITALIA
STAGE:
Description:

II. Tanners Maturity Rating

D. Adolescence (10-20 y/o)

I. HEADS/S/FIRST
Home: Space/measurement; privacy; frequent geographic moves; neighborhood

Education/School: Frequent school changes, repetition of subject, teachers reports, vocational goals, educational clubs/ groups, learning disabilities,
achievements, absences; Eating Habits/Behaviors.

Abuse: Physical, sexual, emotional, verbal abuse, parental discipline

Drugs: tobacco, alcohol, marijuana, inhalants, club drugs, rave parties, drug of choice, age of initiation, frequency; mode of intake; rituals, alone/with peers, quit
methods and number of attempts

Safety:

Seat belt, protective gears, sports safety measures, hazardous activities; driving while intoxicated;

Sexuality/ Sexual Identity:

Suicidal Attempts/ Ideation.

Reproductive health, use of contraceptives, presence of STI, feelings, pregnancy; sexual practices, sexual partners.

Family/ Friends: Family constellation, genogram, civil status/relationships, type of family, family occupations, history of addiction 1 st and 2nd degree
relatives, parental attitude on drugs, parental rules, peer cliques, gangs, preferred friends

Image: Height and weight perceptions, body musculature and physique, appearance, self-image

Recreation: Sleep, exercise, sports; activities, total hours spent for recreations.

Spirituality & Connectedness: Hope or security for future; religion; personal spirituality practices, effects of medical care and life issue involvement

Threats/ Violence: Self-harm, harm to others, running away, cruelty to animals, guns, fights, arrest, stealing, fight in school

II. For Female:

Age of Menarche: ____________
Menstrual History (cycle, regularity, frequency, duration, pain): _______________________________________________________
LMP: _____________
Self- Breast Examination Practices:

VIII. SOCIOECONOMIC HISTORY

(NOTE!) Living circumstances: place and nature of dwelling, number of persons living in the house; Economic circumstances: members of family who work;
source of income/funds

IX. ENVIRONMENTAL HISTORY:

(NOTE!) Environmental circumstances: exposure to cigarette smoke and other pollutants (specify and duration of exposure); Garbage disposal; Sewage
disposal; Water source for drinking and washing.

X. REVIEW OF SYSTEMS
General
Weight loss or gain
Fatigue
Fever or chills
Weakness
Trouble sleeping
Activity level
Delay in growth
Skin
Rashes
Lumps
Itching
Dryness
Acne
Color changes
Hair and nail changes
Head
Headache
Head injury
Neck Pain
Ears
Decreased hearing
Ringing in ears
Earache
Drainage
Eyes
Vision Loss/Changes
Glasses or contacts
Pain
Redness
Blurry or double vision
Flashing lights
Specks
Glaucoma
Cataracts
Dryness
Lacrimation
Last eye exam &
result:_________________

PHYSICAL EXAMINATION

Nose
Stuffiness
Discharge
Itching
Hay fever
Nosebleeds
Sinus pain
Throat/Mouth
Bleeding
Dentures
Sore tongue
Dry mouth
Sore throat
Hoarseness
Thrush
Non-healing sores
Toothache
Neck
Lumps
Swollen glands
Pain
Stiffness
Breasts
Lumps
Pain
Discharge
Self-exams
Respiratory
Cough
Sputum
Hemoptysis
SOB/DOB
Wheezing
Painful breathing
Cardiovascular
Chest pain or discomfort
Tightness
Palpitations

Easy fatigability
Orthopnea
Fainting spells
Cyanosis
Gastrointestinal
Swallowing difficulties
Heartburn
Change in appetite
Nausea/Vomiting
Change in bowel habits
Rectal bleeding
Constipation
Diarrhea
Food intolerance
Abdominal pain
Pica
Genitourinary
Frequency
Urgency
Burning or pain
Blood in urine
Incontinence
Change in urinary strength
Change in urine color
Enuresis
Discharge
Edema of hands and feet
Prepubertal: discharge and
itching
History of Menstrual Period:
(onset, frequency, regularity,
pain and LMP)
_____________________
_____________________
Peripheral Vascular
Calf pain with walking
Leg cramping
Varicose veins

Musculoskeletal
Muscle or joint pain
Stiffness
Back pain
Redness of joints
Swelling of joints
Trauma
Limping
Limitation of motion
Neurologic/Behavioral
Nervousness
Stress
Depression
Memory loss
Dizziness
Fainting
Seizures
Weakness
Numbness
Tingling
Tremor
Paralysis
Eating problems
Personality or behavioral
changes
Temper outbursts
Hallucinations
Hematologic
Ease of bruising
Ease of bleeding
Past transfusions and
reactions: ______________
Endocrine
Heat or cold intolerance
Sweating
Frequent urination
Polydipsia
Polyphagia
Palpitations

GENERAL SURVEY

(NOTE!) Mental state/sensorium; level of activity; height; grooming, dress and personal hygiene; presence of CP distress or color; ambulatory or bedridden; nutritional
state (well, under, or over nourished), state of hydration, ill-looking (well, mild, or severe: refer to Index A for Acute Illness Observational Scale)

VITAL SIGNS
Blood Pressure:
R-Arm ____________ mmHg
L-Arm ____________ mmHg
Cardiac/Pulse Rate: ________ bpm
Respiratory Rate: _________ cpm
Oxygen Saturation: ________ %

Temperature:
Rectal: __________
Oral: __________
Axillary: ___________
Tympanic: _________
Temporal Artery: __________

Pain Scale: ________________

(NOTE!) - Obtain BP if >3 y/o.

- Correlate CR/PR and RR to childs condition where it is clinically significant, (i.e. was the child asleep, active, afebrile (~ 5-7 cpm / C
> 37 C), crying, struggling etc.
- RR to CR ration is about 1:4.

ANTHROPOMETRIC MEASUREMENTS
Weight: ___________ kg (Percentile: ___)
Length (<2 y/o): __________cm (Percentile: ___)
Height ( 2 y/o): __________cm (Percentile: ___)

Head Circum. (<3 y/o): _______ cm

Chest Circum.: _________ cm
Abdominal Circum.: _________ cm

(Percentile: ___)

BMI: _____________ (Percentile: ___)

For children with growth disorders:
Arm Span: ___________ cm
U/L Ratio: __________
(NOTE!) See Appendix A for the percentiles.

HEAD TO TOE PHYSICAL EXAMINATION:

SKIN: After first year of life, techniques are the same with adults. Look for color, tissue/skin turgor, rash or eruptions, hemorrhages, scars, edema, jaundice. Note
for milia, erythema toxium, lanugo, Epstein pearls, Mongolian spots etc.

HEAD: Assess for hair, shape, contour, scalp, fontanels, sutures; Hair is described based on quantity, color, texture, surface characteristics, and strength.; Look
for swelling, caput succedaneum, cephalhematoma.

FACE: Inspect for symmetry, expression, unusual facies, deformities, lumps, bumps; and adenoid facies.

EYES: Inspect lids, conjunctiva, pupils, extraocular movements, vision; strabismus, opacities, discharge, ROR up to 24 mos, corneal light reflex and cross cover
test.

EARS AND MASTOIDS: Size, shape, location and position in relation to the rest of the head, discharge, mastoid areas, otoscopy and hearing using tuning
fork.

NOSE AND PARANASAL SINUSES:

Patency, alar flaring, discharge and character, position of septum, sinus tenderness.

MOUTH AND THROAT: Lips, gums, tongue, mucous membrane, dentition, palate, posterior pharyngeal wall, and tonsils.

NECK: Venous engorgement, flexibility, rigidity, masses, lymph nodes.

CHEST AND LUNGS: Inspect size and shape, movement with respirations, chest retractions, chest expansion, vocal fremitus, check breast contour and
discharge (refer to Tanner Staging). Percuss, and auscultate for breath sounds.

HEART AND PERIPHERAL VASCULAR: Observe precordium, visible pulsations, apex beat, thrills, heart sounds and pulses.

ABDOMEN: Inspect size, shape, prominent vessels, striae, pulsations, peristaltic movements, movement in relation to respiration, umbilical hernia, abdominal
distention, abdominal circumference, auscultation of bowel sounds, percussion, palpation of liver span, spleen, tenderness, masses. Assess for kidneys and
costrovertebral angle tenderness. Check inguinal regions for hydrocele, lymph nodes and hernias.

MALE GENITALIA:

Inspect penis, prepuce and glans, discharges, skin lesions, urethral orifice, palpate for the testes.

FEMALE GENITALIA:

Inspect vulvovaginal area for lesions and check for discharges, vaginal introitus, lacerations and discharges, and shape of hymen.

ANUS AND RECTUM: Location, patency, fissures, lesions, tags, hemorrhoids, pinworms or prolapse. In rectal exam, assess for sphincter tone, mass,
impacted feces and tenderness.

UPPER AND LOWER EXTREMITIES:

Check for clubbing, cyanosis, signs of inflammation, range of motion and joint deformities; hip dislocations in
newborn and vertebral spine. Assess for peripheral pulses, lymph nodes; and edema.

Musculoskeletal:

Peripheral Vascular:

Radial
Right

Femoral

Popliteal

Dorsalis Pedis

Posterior Tibial

Left
NERVOUS: Assess for sensations; gait; strength and coordination; deep tendon reflexes; development; cerebellar function and cranial nerves.
Mental Status: (See also Mini-Mental Status Examination at APPENDIX A)

Cerebellar: (Perform rapid alternating movement; Finger-to-nose; Heel-to-sheen)

Gait/Stance/Balance: (Gait/Stance: ask the patient to walk across the room; Balance: Test for Romberg and Pronator Drift)

Motor and Strength: (Grade of muscle strength bilaterally; see APPENDIX A)

Sensory:

(Test for sensations bilaterally; see APPENDIX A)

Cranial Nerves:
Cranial Nerves/Function
I - Olfaction
II - Visual Acuity
III, IV, VI Extraocular Movements
V - Motor and Sensation
VII - Facial
VIII - Hearing
IX, X Swallowing and Gag Reflex
XI Spinal Accessory
XII - Hypoglossal

Remarks

Reflexes:
Biceps

Triceps

Brachioradiali
s

Patellar

Achilles

Plantar

Right
Left

Development: (For children >3 y/o). Ask to draw a picture or copy objects, and discuss their pictures to test also for fine motor
and language or USE DENVER II; SEE APPENDIX A)

coordination, cognition

APPENDIX A
Mini-Mental Status Examination
Points
Orientation
Name: season/date/day/month/year (1pt. for each name)
Name: hospital/floor/town/state/country (1pt. for each name)
Registration
Identify three objects by name and ask patient to repeat
Attention and calculation
Serial 7s; subtract from 100 (e.g., 9386797265) (1 pt. for each subtraction)
Recall
Recall the three objects presented earlier
Language
Name pencil and watch (1pt. for each object)
Repeat "No ifs, ands, or buts"
Follow a 3-step command (e.g., "Take this paper, fold it in half, and place it on the table")
(1pt. for each command)
Write "close your eyes" and ask patient to obey written command
Ask patient to write a sentence
Ask patient to copy a design (e.g., intersecting pentagons)

Patients Score
(5)
(5)
(3)
(5)
(3)
(2)
(1)
(3)
(1)
(1)
(1)
Total

(30)

Muscle Strength Examination

Major Muscle Groups:
Elbow
flexion (C5, C6biceps)
extension (C6, C7, C8triceps)
Wrist extension (C6, C7, C8, radial nerveextensor carpi radialis longus and brevis)
Grip (C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Opposition of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4 iliopsoas)
Adduction at the hips (L2, L3, L4adductors)
Abduction at the hips (L4, L5, S1gluteus medius and minimus)
Extension at the hips (S1gluteus maximus)
Flexion at the knee (L4, L5, S1, S2hamstrings)
Dorsiflexion (mainly L4, L5tibialis anterior)
Plantar flexion (mainly S1gastrocnemius, soleus) at the ankle

Right

Left

Sensory Examination
Sensory System
A. Spinothalamic: pinprick, temperature, light touch
Shoulders (C4)

Right
Left
(Rate from 0-100%)

Inner and outer aspects of the forearms (C6 and T1)

Thumbs and little fingers (C6 and C8)
Fronts of both thighs (L2)
Medial and lateral aspects of both calves (L4 and L5)
Little toes (S1)
Medial aspect of each buttock (S3)
B. Posterior Column:
Position sense
Vibration
C. Sensory Cortex (Discrimination)
Stereognosis
Graphesthesia

(Intact or Not)

(Intact or Not)