PEDIATRIC HISTORY AND PHYSICAL EXAM TEMPLATE

IDENTIFYING DATA
Vital Signs
NAME: BP:
AGE/SEX: CR:
ADDRESS: RR:
NUMBER OF ADMISSIONS: Temp:
DATE OF ADMISSION: O2Sat:
RELIGION: Weight:
BIRTHDATE: Height:
INFORMANT:
RELEIABILITY:

CLINICAL HISTORY

Chief Complaint:

History Present Illness:

HC:
CC:
AC:
BL:
BW:
BS:
AS:
Past Medical History:

Prenatal/Perinatal:
Duration of pregnancy: (term/preterm)
Details of labor and delivery:
Age of Mother:
OB Score:
Place:
Assisted by:

Antenal
Prenatal Check-up:
Drugs taken during pregnancy:
Maternal illness prior or during pregnancy:
Maternal conditions during pregnancy:
Exposure to infectious disease, radiation, drugs
Condition of infant at birth:

Birth and Neonatal Period:

Condition and vigor of infant at birth:
Birth weight:
Postnatal problems: (-) neonatal cyanosis (-) jaundice (-) convulsions, (-) skin eruptions, (-) initial feeding
Vit K
BCG
Hep B
Crede’s Prophylaxis

Feeding History:
Initial feeding, breast or bottle:
Kind of feedings:
Complementary feeding
Current dietary intake balance:
Vitamin supplements:

Growth and Development:

AGE GROSS MOTOR VISUAL-MOTOR LANGUAGE SOCIAL

Family History:
Parent’s Health:
Maternal:
Paternal
Social History:
Father’s Age & Occupation:
Mother’s Age & Occupation
Family Income:
Type of House:
Source of drinking water:
Past Illnesses
Infectious disease
(-) Measles
(-) Rubella
(-) Mumps
(-) Chicken pox
(-) Pertussis
(-) Diphtheria
(-) Poliomyelitis
(-) Scarlet fever.

General:
Integumentary:
HEENT:
Respi:
CV:
GIT:
GUT:
HEMMA:
MS:
Endo:
Neurologic:
PHYSICAL EXAM:
General:
VS:
Anthropometric:
Skin:
Head:
Eyes:
Ears:
Neck:
Respi:
Abdomen:
GU:
Extremities:
Neuro:
Cranial Nerves
I-able to smell
II- PERRLA
III, IV, VI – able to follow objects
V-
VI-
Reflexes:
Biceps:
Supinator:
Triceps:
Knee:
Ankle:
Palmar:
Babuski:
Rooting:
Moto:
Tonic neck:
Meningcal Signs

SCALANT FEATURE:
IMPRESSION:
DIFFERENTIAL DIAGNOSIS: