Republic of the Philippines

Province of Zamboanga del Norte

Siocon District Hospital
Siocon, Zamboanga del Norte

PEDIATRIC HISTORY AND PHYSICAL EXAMINATION

Name: __________________________________ Age: ____ Sex:_______Birthday: ___/ ____/ _____

Address: ______________________________________ Informant: ___________________________

Chief Complaint: ____________________________________________________________________

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History of Present Illness: _____________________________________________________________

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Past History Past Medical History
Prenatal: ________________________________________
PNC started: ______ Where: __________ ________________________________________
Maternal Illness: ____________________ ________________________________________
Medications: _______________________
Others: ____________________________ Previous Hospitalizations:
Date Diagnosis Medication
Natal: __________ __________ _______________
Where delivered: __________________ __________ __________ _______________
Assisted by: ______________________ __________ __________ _______________
Condition at birth: _________________
____________________________ Family History:
Allergy: __________ Epilepsy: _____________
Post Natal: Blood Ds: _________ Hypertension: ________
Feeding: ___________________________ Diabetes: _________ Tuberculosis: ________
Others: ____________________________ Others: _________________________________

Immunizations (doses): Allergies

BCG ______ Measles ______ PCV ______ Foods: __________________________________
DPT ______ MMR _______ Others _____ Meds: ___________________________________
OPV ______ Hib _________ Others: __________________________________
HepB _____ Rotavirus ____

Developmental Milestones:
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Review of System: Genital, urinary:
Skin: Neuromuscular:
HEENT: Muscle/Skeletal:
Respiratory: Hematologic:
Cardiac: Others
Gastrointestinal:

PHYSICAL EXAMINATION

Temp: PR: RR: B/P: O2 sat: Wt:

General Survey: awake in respiratory distress coherent oriented

Skin: (-) pallor (-) Cyanosis (-) Rashes

HERENT: Anicteric Schlerae Palpebral Conjunctiva (-) ear and nasal discharges
(-) tenderness (-)Lymphadenopathy

Chest and Lungs: Chest Expansion Breath Sounds (-) Chest Indrawing

Heart: Dynamic Precordium Rate Rhythm Murmur

Abdomen: (-)Distension Bowel Sounds Tenderness

Extremities: Pulse Motor Sensory

Genitalia: CVA tenderness

Neurologic: Seizure Paralysis

IMPRESSION:

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Physician’s Name and Signature