SAINT LOUIS UNIVERSITY Associated Manifestation: ________________________________
SCHOOL OF MEDICINE Relations to ADL: _______________________________________
DEPARTMENT OF PEDIATRICS
GENERAL DATA:
Name: ________________________________________________
Age: ____ Birthday: __________ Birthplace: __________________
Sex: ____ Nationality: _______________ Religion: _____________
Classification: __________________________________________
Address:_______________________________________________
Occupation: ___________________________________________
Date of Admission/ Consultation: __________ # Consultation: ___
Informant: __________________________ Reliability: ________%
CHIEF COMPLAINT:
______________________________________________________
______________________________________________________
HISTORY OF PRESENT ILLNESS:
Onset: ________________________________________________
Location: ______________________________________________
Radiation: _____________________________________________
Duration: ______________________________________________
Timing/Frequency: ______________________________________
Quality: _______________________________________________
Quantity: ______________________________________________
Severity: ___________________________________ (Rate 1 10)
Precipitating Factor:_____________________________________
Drug intake: ___________________________________________
Radiation: _____________________________________________
Exposure/Infectious disease: ______________________________
Consultation: __________________________________________
Where & When: ________________________________________
Medication: ___________________________________________
Drug, Dosage: __________________________________________
Duration of treatment: ___________________________________
Prescribed or Self Medication: _______ _____________________
Effect of Drug: _________________________________________
Remedies (done at home): ________________________________
Change of Position: ______________ Diet: ___________________
Herbal Medicine: ________________ Massage: _______________
Rituals: ____________________ Religious belief: _____________
Effect: ________________________________________________
PERSONAL HISTORY
**Prenatal, Birth, & Neonatal: Included only in patients <2 years
old or if related to the illness of children > 2 years old)
A. GESTATIONAL HISTORY (PRENATAL HISTORY)
Age of mother (during pregnancy):_________________________
OB score: G: _____ P: ______ (T:______ P:_____ A:_____ L:_____)
Pregnancy: Planned/Unplanned and Wanted/Unwanted
Pregnancy: With/Without Attempt of Abortion
Health: ______________________________________________
Nutrition: _____________________________________________
Infections: _____________________________________________
Duration of Gestation: ___________________________________
Prenatal Care: _______________________________________
Where: Health Center/Private OB/OPD/Other: ________________
Associated signs and symptoms:
Nausea: ______ Vomiting: _______ Urinary Disturbances: ______
Fatigue: ______ Breast tenderness & tingling sensation: ________
Chloasma: ______ Melasma: _________ Weight Gain: _________
Prepregnant weight: _____ Other Signs & Symptoms: _________
Ultrasound: ____________________________________________
Urinalysis: _____________________________________________
Other Test: ____________________________________________
Medication: ___________________________________________
Vitamins/Food Supplements: ______________________________
Vaccination: ___________________________________________
Quickening: ____________________________________________
Alcohol: _______________________________________________
Cigarette Smoke: _______________________________________
Toxic Chemicals: ________________________________________
Accident: ______________________________________________
Trauma: ______________________________________________
Travel: ________________________________________________
B. BIRTH (NATAL HISTORY)
AOG: Term/Preterm/Postmature: __________________________
Hours of Labor: _________________________________________
Manner of Delivery: NSVD/LCCS: ___________________________
Place of Delivery: _______________________________________
Person who attended Delivery: ____________________________
Bag of Water: __________________________________________
Birth weight: ___________________________________________
APGAR Score: __________________________________________
C. NEONATAL HISTORY
Jaundice: ______________________________________________
Convulsions:___________________________________________
Haemorrhage: _________________________________________
Respiratory or feeding difficulty: ___________________________
Congenital abnormality: __________________________________
Birth injury: ____________________________________________
Blood type: ____________________________________________
D. FEEDING HISTORY
INFANCY (<2 YEARS OLD)
Type of feeding: Breastfeeding/Formula Milk/Mix: ____________
Feeding times/day: ______________________________________
Reason (if not breastfeeding): _____________________________
Formula Milk Used: _____________________________________
Dilution and Amount/day: ________________________________
Bottle feeding or Cup feeding: _____________________________
Complimentary Foods: ___________________________________
Age introduced: ________________________________________
Consistency: Pureed/Soft/Lumpy/Table foods: ________________
Frequency of feeding/day: ________________________________
Sample Diet:
BREAKFAST LUNCH DINNER SNACK
TOTAL
Acute Caloric Intake: ____________________________________
RENI: _________________________________________________
Food intolerance: _______________________________________
Multivitamins/Iron supplements:___________________________
Dosage: _______________________________________________
Frequency: ____________________________________________
Caregiver: Mother/Father/Grandparents/Siblings/Uncle/Aunt/
Cousin/Household Helper/Other: __________________________
CHILDHOOD AND ADOLESCENT (2 20 YEARS)
Appetite: Good/Picky Eater: _______________________________
BREAKFAST SNACK AM LUNCH SNACK PM DINNER
TOTAL
Acute Caloric Intake: ____________________________________
RENI: _________________________________________________
Assess if basic food group are eaten daily: ___________________
Food likes: _____________________________________________
Food dislikes: __________________________________________
Feeding difficulties: _____________________________________
Multivitamins/Iron supplements: __________________________
Dosage: _______________________________________________
Frequency: ____________________________________________
E. GROWTH & DEVELOPMENTAL
YOUNG CHILDREN (1-5 YEARS)
MIDDLE CHILDHOOD (6-11 YEARS)
ADOLESCENCE (10-20 YEARS)
Home: ________________________________________________
Education: _____________________________________________
Eating behaviour: _______________________________________
Activities: _____________________________________________
Drugs: ________________________________________________
Sexual: _______________________________________________
Suicidal Ideations: ______________________________________
F. PAST ILLNESS
Contagious disease: Measles/Varicella/Mumps/Pertusis/Other:
______________________________________________________
Clinical Course: _________________________________________
Disease/Age: ___________________________________________
Severity: ______________________________________________ Signs & Symptoms: ______________________________________ SOCIOECONOMIC & ENVIRONMENTAL HISTORY

Complications: _________________________________________ Course of Illness: _______________________________________ Father/Age: ____________________________________________

Other Medical Illness: ____________________________________ Disease/Age: ___________________________________________ Occupation: ___________________________________________

Hospitalized? _______ Where: ____________________________ Severity: ______________________________________________ Educational Attainment: _________________________________

Duration: ______________________________________________ Complications: _________________________________________ Mother/Age: ___________________________________________

Disease/Age: ___________________________________________ IMMUNIZATION HISTORY & TUBERCULIN TEST Occupation: ___________________________________________

Severity: ______________________________________________ Types/Age/Date given/Place/Untoward reactions: _____________ Educational Attainment: _________________________________

Complications: _________________________________________ Source of Income: ______________________________________

Surgical Operation: ______________________________________ FAMILY HISTORY: Exposure to Cigarette smoke: _____________________________

Condition: _____________________________________________ Father/Age: _______ Status: Alive:________, Deceased:________ Duration of exposure: ___________________________________

Type: _________________________________________________ Fathers Condition: ______________________________________ Exposure to environmental pollutants: ______________________

Place: ________________________________________________ Mother/Age: _______Status: Alive: ________, Deceased: _______ Duration of exposure: ___________________________________

Disease/Age: ___________________________________________ Mothers Condition: _____________________________________ Living arrangement (family/friends/relatives): ________________

Severity: ______________________________________________ Siblings: #Brother: _______________ #Sister: ________________ Physical and social aspect of home: _________________________

Complications: _________________________________________ Siblings/Age: ___________________________________________ # Storey: ____________________ # rooms: __________________

Allergy/Eczema/Food or Drug Sensitivity/Other: ______________ Siblings/Health status: ___________________________________ # Occupants: _________________ # CR: _____________________

Disease/Age: ___________________________________________ Position in the family: ____________________________________ Window type: ________________ Ventilation: _______________

Severity: ______________________________________________ Heredofamilial diseases: _________________________________ Location of residence: ___________________________________

Complications: _________________________________________ HPN: _____________ Diabetes: ___________ Arthritis: ________ Interpersonal relationship: ________________________________

Asthma: ______________________________________________ PTB: _____________ CVD: _______________ Asthma: _________ Sources of drinking water: ________________________________

Disease/Age: ___________________________________________ Allergies: _________ Cancer: ____________ Psychiatric: _______ Source of domestic water: ________________________________

Severity: ______________________________________________ Hematologic: __________________ Seizures: ________________ Sanitation (inside and outside): ____________________________

Complications: _________________________________________ Peptic ulcer: _________ BPH: ____________ Twinning: ________ Garbage disposal: _______________________________________

Injury: ________________________________________________ Chromosomal/Congenital Abn: ____________________________ Type of toilets disposal: __________________________________

Effect: ________________________________________________ Others: _______________________________________________ Pets: _________________________________________________

REVIEW OF SYSTEMS: ) number of pregnancies, ( ) number and types of
deliveries, ( ) abortions, ( ) birth control method, (
1. GENERAL: ( ) fatigue, ( ) weight change, ( ) fever, (
) menopause (age)
) chills, ( ) delay in growth
11. MALE GENITALIA: ( ) pain, ( ) swelling, ( )
2. SKIN: ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( )
urethral discharge, ( ) hernias, ( ) testicular pain, (
hives, ( ) pigmentation, ( ) acne, ( ) Pruritus
) masses, ( ) history of venereal diseases, ( ) erectile
3. HEAD and NECK: ( ) headache, ( ) trauma, ( ) pain, (
dysfunction/ potency, ( ) sexual habits, ( ) ulcers
) stiffness, ( ) swelling
12. MUSCULOSKELETAL: ( ) muscle pains, ( ) joint pains,
a. EYES: ( ) pain, ( ) diplopia, ( ) scotoma, (
( ) cramps, ( ) weakness, ( ) stiffness, ( ) history
) visual dysfunction , ( ) dryness, ( )
of trauma, ( ) swelling, ( ) limitation of motion, (
redness, ( ) tearing, ( ) use of corrective
) backache
lenses
13. HEMATOLOGICAL: ( ) anemia, ( ) excessive
b. EARS: ( ) difficulty hearing/ deafness, ( )
bleeding, ( ) easy bruising, ( ) past transfusions,
tinnitus, ( ) pain, ( ) discharges, ( )
( )pallor
vertigo/dizziness
14. ENDOCRINE AND METABOLIC: ( ) heat/cold
c. NOSE: ( ) epistaxis, ( ) dryness, ( )
intolerance ( ) weight/ change, ( ) polydipsia, ( )
pain, ( ) discharges, ( ) obstruction, (
polyphagia, ( ) polyuria, ( ) hair change
) smell dysfunction, ( ) sneezing
15. NERVOUS SYSTEM: ( ) headaches, ( ) syncope, (
d. MOUTH: ( ) soreness, ( ) pain, ( )
) seizures, ( ) weakness, ( ) head trauma, ( )
ulcers, ( ) hoarseness, ( ) dryness, (
stroke, ( ) sleep disorder, ( ) coordination problem,
)gum and dental problems
( ) sensory disturbance, ( ) motor problem, ( )
4. BREASTS: ( ) discharges, ( ) lump/mass, ( )pain, (
tremors, ( ) memory
) bleeding, ( ) infection
16. PSYCHIATRIC/ EMOTIONAL: ( ) anxiety, ( )
5. RESPIRATORY: ( ) cough, ( ) dyspnea/shortness of
depression, ( ) loss of control/ violence, ( )
breath, ( ) sputum, ( ) hemoptysis, ( ) cyanosis,
nervousness, ( ) memory change, ( ) suicide
( ) wheezing/ asthma, ( ) occupational exposure, ( )
attempts, ( ) substance abuse
tuberculosis/PTB exposure, ( ) past PPD, ( )
previous chest x-ray
6. CARDIAC: ( ) chest pains/discomfort, ( )orthopnea,
( ) dyspnea, ( ) paroxysmal nocturnal dyspnea,
( ) palpitations, ( ) undue fatigue, ( ) edema, ( )
cyanosis, ( ) syncope, ( ) hypertension, ( ) past
heart diseases, ( ) exercise limits
7. VASCULAR: ( ) intermittent claudication, ( ) leg
cramps, ( ) ulcers, ( ) varicose veins
8. GASTROINTESTINAL: ( ) anorexia, ( )
nausea/retching, ( ) vomiting, ( ) dysphagia, ( )
hematemesis, ( )indigestion, ( ) melena, ( )
hematochezia, ( )heartburn, ( ) abdominal pain, (
) hernia, ( ) hemorrhoids, ( ) use of laxatives
9. RENAL AND INJURY: ( ) dysuria, ( ) hematuria, ( )
incontinence, ( ) nocturia, ( ) urinary frequency, ( )
dribbling, ( ) kidney stones
10. GYNECOLOGICAL: ( ) menarche (age), ( ) cycle, ( )
duration of menstruation, ( ) abdominal bleeding, (
) vaginal discharge, ( ) itchiness, ( )
dysmenorrhea/ pelvic pain, ( ) dyspareunia, ( )
contraceptive use, ( ) history of venereal diseases, (