Pediatrics Wards History Taking Template

GENERAL DATA

Birth: Name: ____________________________________________________________ Delivered: _____ AOG via ( ) NSD/( ) CS by _____________ in _____________ Birth weight: _______ kg ( ) cord coil ( ) meconium stained amniotic fluid Sex: ______ Age: _______ Weigh t: _________ kg Height: ________ cm ( ) Vit K ( ) BCG ( ) NBS: Result: ______________________ ____________ Birthday: _________________________ Birth Place: _____________________  Address: _________________ ________________________ _________________ Complications: _____________________________ Sent home after: _____ days Citizenship: ( ) Filipino ( ) Others: ____________________ ________________ IMMUNIZATION HISTORY ( ) Rotavirus Religion: ( ) RC ( ) INC ( ) Born Again Others: _____________________ __ ( ) BCG ( ) PCV/PPV Date of Admission: ___________________ Time of Admission: ________ AM / PM ( ) DPT 1 ( ) DPT 2 ( ) DPT 3 ( ) OPV 1 ( ) OPV 2 ( ) OPV 3 ( ) Influenza Informant: _______________________________ Reliability: _________________ ( ) Hep B 1 ( ) Hep B 2 ( ) Hep B 3 ( ) Varicella CHIEF COMPLAINT:  COMPLAINT:  ________________________________________________ ( ) Measles ( ) MMR ( ) Hep A ( ) HiB ( ) HPV HISTORY OF PRESENT ILLNESS Given in: ________________ Complications: ______________________________ Please indicate the O nset, nset, P rovocation/  rovocation/ P  a  lliation, Q uality uality of Pain, R egion egion and R adiation, adiation, S everity, everity, Palliation, ime (History),  Aggravating/  Alleviating Factors,  Associated Symptoms,  Attributions/  Adaptations T ime NUTRITIONAL AND FEEDING HISTORY ( ) Breastfed Duration: _________________ Age Weaned: ________________ ( ) Milk Formula: _________________ Dilution: ______ ______oz Q _____ hrs Started complimentary feeding: _______ months 24-hour food recall: Breakfast: _________________________________________________________ Merienda: _________________________________________________________ Lunch: ____________________________________________________________ Merienda: _________________________________________________________ Dinner: ___________________________________________________________ Food Preferences:  Preferences:  __________________________________________________ GROWTH AND DEVELOPMENTAL HISTORY NORMAL ACTUAL NORMAL ACTUAL MILESTONES MILESTONES Regards 1 Drinks from cup 9 - 17 Smiles 2 Toilet-trained 14 - 48 Turns head 3 Feeds self 18 – 36 Holds head 4 Undresses 20 - 36 Rolls over 5 Vertical/circular strokes 2 yrs Transfers object 6 Copies circle 3 yrs Sits briefly 7 Writes name Creeps 8 Says mama/dada 5 – 14 Pulls up 9 2-3 word sentences 2 yrs Cruises 10 Knows name & gender 3 yrs Stands alone 12 Asks questions 3 yrs Walks alone 15 Counts REVIEW OF SYSTEMS Runs 18 Says songs/tells stories 4 yrs  (–) fever, (–) anorexia, (–) weight loss Constitutional: (–) Constitutional: Up and down stairs 2 yrs Asks meanings of words 5 yrs HEENT: (–) ear pain, (–) aural discharge, (–) epistaxis, (–) sore throat Schooling: ____________________ Performance: ( ) good:________ ( ) poor Cardiovascular: (–) Cardiovascular:  (–) cyanosis, (–) palpitations, (–) orthopnea, (–) easy fatigability PAST MEDICAL HISTORY Respiratory: (–) Respiratory:  (–) dyspnea, (–) hemoptysis Gastrointestinal: (–) Gastrointestinal:  (–) vomiting, (–) diarrhea, (–) constipation ( ) Measles ( ) Chickenpox ( ) Mumps ( ) Asthma Genitourinary: (–) Genitourinary:  (–) discharge, (–) oliguria, (–) dysuria ( ) Previous Hospitalizations: ______________________ ____________________ Endocrine: (–) Endocrine:  (–) heat/cold intolerance, (–) polyuria, (–) polydipsia, (–) polyphagia ( ) Surgical Procedures: ___________________________ When? ____________ Musculoskeletal: (–) Musculoskeletal:  (–) joint pain, (–) muscle pain  Allergies: ( ) Drug: ________________ __ ( ) Food: _________________ ___ Hematologic: (–) Hematologic:  (–) pallor, (–) bleeding manifestations, (–) easy bruising Maintenance Medications: _____________________________________________ Neurologic: (–) Neurologic:  (–) tremors, (–) increase in sleeping time FAMILY HISTORY BIRTH AND MATERNAL HISTORY Maternal:  Age of the mother: _______ OB Score: G P ( - - - ) ( ) smoker ( ) alcoholic beverage drinker ( ) illicit drug use: _______________ Prenatal Check-up: total of ___________ PNCUs Start: _____________________ AOG Attended by: _________________________ Last: ______________________ AOG Attended by: ________________________ Prenatal Medications: ________________________________________________ UTZ: _________ AOG: ______________ _________ AOG: ______________ Maternal Illnesses During Pregnancy: ____________________________________ Labs done/Meds taken: _______________________________________________ Date Sex AOG Manner Place Attendant Complications G1 G2 G3 G4 G5

(indicate whether maternal or paternal side)

Similar illness in the family: ___________________________________________ ( ) PTB ( ) seizure ( ) bronchial asthma ( ) hypertension ( ) cancer ( ) diabetes mellitus ( ) heart disease ( ) kidney diseases Others: ____________________________________________________________ SOCIAL AND ENVIRONMENTAL HISTORY House: ________ storey ( ) concrete ( ) wooden Ventilation: ________________ Lighting: __________________ No. of household members: _________ Drinking water: _______________________ ____ If tap, boiled? ( ) Yes ( ) No Garbage Disposal: _______________ _____ x/week Toilet: ________________ ( ) History of travel: _______________________ _____ When? ______________ ( ) Exposure to smoking ( ) Nearby Dumpsite ( ) Nearby factories ( ) Pets: _____________________ ____ Stay inside the house? ( ) Yes ( ) No  !" $%&'() *+ $' ,- . /012

PSYCHOSOCIAL ASSESSMENT FOR ADOLESCENTS (HEADSSFIRST) HOME. Space, privacy, frequent geographic moves, neighborhood.

EDUCATION/SCHOOL. Frequent school changes, repetition of a grade/ in each subject, teachers’ reports, vocational goals, after-school educational clubs (language, speech, math, etc.), learning disabilities

ABUSE. Physical, sexual, emotional, verbal abuse; parental discipline

DRUGS. Tobacco, alcohol, marijuana, inhalants, “club drugs,” “rave” parties, others. Drug of choice, age at initiation, frequency, mode of intake, rituals, alone or with peers, quit methods, and number of attempts

SAFETY. Seat belts, helmets, sports safety measures, hazardous activities, driving while intoxicated

SEXUALITY/SEXUAL IDENTITY. Reproductive health (use of contraceptives, presence of sexually transmitted infections, feelings, pregnancy)

FAMILY AND FRIENDS. Family: Family constellation, genogram, single/ married/separated/divorced/blended family, family occupations and shifts; history of addiction in 1st- and 2nd-degree relatives, parental attitude toward alcohol and drugs, parental rules; chronically ill physically or mentally challenged parent. Friends: peer cliques and configuration (“preppies,” “jocks,” “nerds,” “computer geeks,” cheerleaders), gang or cult affiliation IMAGE. Height and weight perceptions, body musculature and physique, appearance (including dress, jewelry, tattoos, body piercing as fashion trends or other statement)

RECREATION. Sleep, exercise, organized or unstructured sports, recreational activities (television, video games, computer games, Internet and chat rooms, church or community youth group activities [e.g., Boy/Girl Scouts; Big Brother/Sister groups, campus groups]). How many hours per day, days per week involved? SPIRITUALITY AND CONNECTEDNESS. Use HOPE* or FICA † acronym; adherence, rituals, occult practices, community service or involvement HOPE, hope or security for the future; organized religion; personal spirituality and practices; effects on medical care and end of life issues. †  FICA, faith beliefs; importance and influence of faith; community support.

THREATS AND VIOLENCE. Self-harm or harm to others, running away, cruelty to animals, guns, fights, arrests, stealing, fire setting, fights in school

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