PEDIATRIC HISTORY TAKING Associated signs & symptoms: ____________________

Date & Time: ________________________________ ___________________________________________

Source of Hx/Informant: Effects on problem & sleep: _____________________

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% Reliability: __________________________
Medication: _________________________________
General Data
___________________________________________
Name: _____________________________________
Prenatal History
Age: _____________
Mother’s age: ______________________
Sex: _____________
Mother’s OB score during the time of pregnancy: G__P__
Nationality: _________________________ (FPAL) _____________________

Religion: ____________________________ Prenatal care: ________________________________

Address: ___________________________________ ___________________________________________

__________________________________________ Laboratories taken: ___________________________

Date of birth: ______________________________ ___________________________________________

Place of birth: ______________________________ Illnesses during pregnancy: ______________________

Date of admission: ___________________________ ___________________________________________

No. of admission: ____________________________ Drugs taken during pregnancy: ____________________

Place of admission: ____________________________ ___________________________________________

Smoking/ Alcohol intake: ________________________

Chief Complaint: ______________________________
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History of Present Illness
Natal/Postnatal History
Onset & duration: _____________________________
Age of Gestation: ____________________________
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Birth rank: _________________________________
Nature & character: ___________________________
Mode of delivery:
___________________________________________ ___________________________________________

Severity: ___________________________________ Where delivered:

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Aggravating condition: _________________________
Who attended delivery?
__________________________________________ ______________________________________

Relieving conditions: ___________________________ Condition upon delivery:

_______________________________________
___________________________________________
Birth wt.: ___________________________________
Perinatal complications: _________________________ Personal/Social History

___________________________________________ Age of parents & work of:

Duration of stay in hospital: _____________________ Father _____________________________________

Feeding History Mother _____________________________________

Type of feeding: ______________________________ Dwelling place: _______________________________

Age when solid were taken: ______________________ ___________________________________________

Growth & Development Logical Impression

Age when major developmental milestone were acquired: ___________________________________________

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___________________________________________
___________________________________________
___________________________________________
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Immunization History

___________________________________________

___________________________________________

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Past Medical History

Past illnesses/hospitalization: ____________________

___________________________________________

___________________________________________

Allergies: ___________________________________

___________________________________________

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Family Medical History

Present state of health: ________________________

___________________________________________

Presence of chronic diseases: ____________________

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Presence of heredofamilial diseases: _______________

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