INFORMANT & RELIABILITY:

CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

Medical problems/ Previous Hospitalizations:
Latest hospitalizations:
Infections and Medications Taken:
Allergies: ( ) food:

( ) Dengue Fever, ( ) Typhoid Fever

( ) Chicken pox, ( ) Measles
( ) drugs:

BIRTH HISTORY:
Antenatal: Prenatal check-up started at ____________ Place ___________________ TT:____ Infections
_______________________
Maternal Illnesses: ( ) bleeding
( ) preeclampsia/eclampsia ( ) UTI
Natal: Type Delivery ______________ Place ___________ Assisted by_____________ BW. __________Term _____ ( )
Resuscitation
Neonatal: APGAR Score: ______, color:______, abnormalities: __________, convulsions: ___________,
fever:________
Nutrition: Exclusive breastfeeding:_________, Mixed feeding:_______, Milk formula:__________ preparation
________water _____
Solid food: ______, Appetite: ________, Vitamins:____________________, Present
Diet:_______________________________
DEVELOPMENTAL MILESTONES:
Regards face: ______ Rolls over: __________ Sits alone: _____________ Creeps: _________Walks w/support:
_____________ Stands alone_________, Talked mama/papa__________ First teeth: _________ Walks alone
______________
Family History: ( )Hypertension, ( ) DM, ( ) Asthma, ( ) PTB, ( ) Epilepsy, Malignancies, ( ) Thyroid
disease, ( ) Hx of convulsions
IMMUNIZATION: ( ) BCG ( ) DPT ( ) OPV ( )Measles ( ) Hepa B ( ) Pneumococcal ( ) Rotavirus,
Others: _____________________
PERSONAL-SOCIAL HISTORY:
Birth Order: ________ Siblings: ________ Patients school status: ____________________________
Father: _____________________________
Age: ________ Occupation: ______________
Mother: ____________________________
Age: ________ Occupation: ______________
Guardian: ___________________________
Age: _________ Occupation: _____________
Daily Activities: _______________________ Environment:____________________________ Food
Handling________________
REVIEW OF SYSTEMS:
General: ( ) fever ( ) weight loss ( )changes in activity
Skin: ( ) rashes ( ) itchiness ( ) discoloration
Head: ( ) lesions ( ) scars ( ) headache
Eyes: ( ) crossing ( ) redness ( )discharges
Ear: ( ) pain ( ) discharges ( ) hearing loss
Nose: ( ) discharge ( ) sinusitis ( )colds
Mouth & Throat: ( ) sore throat/hoarseness ( ) dryness ( ) oral
lesions
Respi.: ( ) cough ( ) wheezing ( ) apnea ( ) cyanosis ( ) DOB
CV: ( ) murmurs ( ) chest pain

GI: ( ) anorexia ( ) vomiting ( ) LBM ( ) constipation ( ) bloody

stool ( ) abd.pain
GU: ( ) frequency ( ) dysuria ( ) changes in urine output ( )
hematuria
Hema./Lymph.: ( ) bleeding ( ) anemia ( ) jaundice ( ) swollen
glands
Neuromuscular: ( ) seizures ( ) loss of consciousness ( ) joint
pain ( ) weakness
Psych.: ( ) mood changes ( ) sleep problems

IDENTIFYING DATA
Name: ___________________________________________ Age/Sex: __________ Address:
_________________________________
Religion: _________________________ Nationality: ____________________________Date/Time:
___________________________
Referral: __________________________________ Number of Admissions: ______________ ROD:
___________________________

PHYSICAL EXAMINATION:
General Survey:
V/S:

BP =
Temp =

HR =

RR =

Wt =

Ht =

Skin:

Head Circ =
Abd. Circ =
Chest Circ =
GU:

HEENT:
Neck:

Extremities:
Anus:

Chest & Lungs:

Heart:
Abdomen:
NEUROLOGIC EXAMINATION:
Mental Status :
Behaviour: LOC:_______________, Intellegence ____________, emotional status _________________________
Cranial Nerves:
CN I: ( ) anosomia ___________
CN II: light response __________
CN III, IV, VI: follows gaze, drooping
________________
CN V: facial sensation, corneal reflex, jaw jerk
___________
CN VII: facial symmetry ____________
CN VIII: sound response ___________
CN IX: gag reflex __________________
CN X: swallowing ___________________
CN XI: shoulder shruge________
CN XII: protrusion, tremor, & strength of tongue
________
Cerebellar Function: Finger-to-nose
____________________
Romberg Sign
____________________
Motor: Muscle bulk: __________ Muscle tone:
__________
Neonatal Reflex:

Strength (1-5):
(0,+1,+2,+3)

DTRs:
R

Upp
er
Low
er

Sensory: Light touch ______ Pain ______

Temperature ______
Meningeal signs: ( ) Neck rigidity ( ) Kernigs ( )
Brudzinskis
Autonomic functions: Urinary Incontinence
___________
Bowel Incontinence
____________

Ages
Palmar Grasp
Plantar Grasp
Moro/ Startle
Asymmenteric
Tonic
Positive
Support
Rooting
Trunk
Incurvation/
Galants
Placing
&stepping
Landau
Parachute
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
IMPRESSION:

Superficial Reflexes

B-3-4m
B-6-8m
B-4-6m
B-2m
B-2-6m
B-3-4m
B-2m
Bvariable
B-6m
4-6mnone

( ) Abdominal
( ) Cremasteric
( ) Plantar

_______________________________

Pedia Clerk On Duty: