Professional Documents
Culture Documents
Reliability _______________________
Historian:
Group No. 12
GENERAL DATA
No. of admissions in that particular hospital ___ Date of Present Admission _________
Onset ___________________________________________________________________
Character ______________________________
Location ______________________________
Intensity ______________________________
Maternal History:
Age: __________
OB Score: G __ P __ (Full term __- Premature __- Abortions __- Living __)
Health during pregnancy: Poor ( ) Fair ( ) Excellent ( )
Bleeding ( ) Trauma ( ) Hypertension ( )
Gestational DM ( ) Fever ( ) Infections ( )
Radiation exposure ( ) Alcohol ( ) Smoking ( )
Rubella immunity ( ) Hepa B ( ) ROM ( )
Medications/Drugs taken _______________________________________
2. All Children
Neonatal History Y N
APGAR SCORE (if known) __________
Breathing problems ( ) ( )
Remarks:____________________
Use of oxygen ( ) ( )
Remarks:____________________
Need for ICU ( ) ( )
Remarks: ____________________
Problems in nursery ( ) ( )
Meconium-stained ( ) Birth injuries ( ) jaundice ( )
Feeding difficulty ( ) Respi distress ( ) hyperbilirubinemia ( )
Other complications ______________________________
Length of stay in nursery __________
3. Previous hospitalizations
Date Age Reason Length of stay Location
_________ _____ _________________ _____________ _____________
_________ _____ _________________ _____________ _____________
_________ _____ _________________ _____________ _____________
5. History of:
6. Allergies
Medications: ______________________________________________
Food: ______________________________________________
Insects: ______________________________________________
C. IMMUNIZATIONS
Screening Tests
Others: ____________________________________
Language: __________________
1. Language Skills ( ) ( ) ( )
2. Reading Skills ( ) ( ) ( )
3. Writing Skills ( ) ( ) ( )
4. Sequential concepts
& math skills ( ) ( ) ( )
5. Problem solving,
Reasoning & Moral
Development ( ) ( ) ( )
1. Male
Age of onset ____________ Genital Enlargement ____________ Pubic hair _________
2. Female
Age of onset ____________ Breast Enlargement ____________ Pubic hair _________
Menarche ____________ Frequency of Menses ___________ Duration __________
LMP ____________ Dysmenorrhea: Y ( ) N( ) Medications taken _________
Flow: heavy ( ) moderate ( ) mild ( )
E. NUTRITION/DIET HISTORY
1. Infants
Breastfed ( ) Bottle-fed ( ) Frequency ____________ Amount _____ Problems: _________
Age of weaning ____________ Problems in weaning? ____________
Change in formula N( ) Y( ) Why? ________________________
Peculiar eating habits (e.g. pica) ________________________
Vitamins/Mineral supplements (with dose and frequency) ___________________________________
2. Older Children
Appetite: Poor ( ) Good ( ) Excellent ( )
Special diets: ____________________________________
Food Preferences: ____________________________________
Intake of: milk ( ) junk food ( ) Others ____________
Concerns about weight: ________________________
Vitamin/Mineral supplements: ____________________________________
FAMILY HISTORY
Siblings:
Others:_______________________________________
Composition of Family
Nuclear ( ) Extended ( )
Daycare:_______________________________________
Congested area: Y ( ) N( )
Garbage: _____________________
B. ADOLESCENTS (HEADSSS)
1. Home
Living arrangement: _________________
Recent changes in living arrangement? N ( ) Y ( ) _________________
Relationships in home _________________ Issues causing arguments _________________
Economic issues _________________ Stresses in home _________________
Forms of discipline _________________ Anything you like to change in family _________
2. Education
In-school ( ) out of school ( ) employed ( ) _________________
Favorite subject _________________ Average last grading/semester _________________
Problems with classmates/teachers? N ( ) Y( ) _________________
Ever been truant/suspended/expelled? N ( ) Y( )
Future education/employment goals: __________________________________
3. Activities
In spare time: _________________ Hobbies & interests: _________________
Time spent watching TV/playing computer games/using internet: _________________
With whom do you spend time with? _________________
Any close friends? _________________ Are they attending school? Y ( ) N ( )
4. Drug use
Tobacco ( ) alcohol ( ) drugs ( )
If yes: Frequency _________________ amount _________________
How & when started: __________________________________
Effects on daily activities: _________________
5. Sexual activity
Sexual orientation: _________________ Dating? Y ( ) N ( )
Active sexual activity: Y ( ) N( ) Use of contraception: Y ( ) N( )
History of sexual of physical abuse: Y ( ) N( )
6. Suicide/Depression
Feelings of sadness ( ) unmotivation ( ) Hopelessness ( )
Loneliness ( ) Reason? __________________________________
Has he thought of hurting himself? Y ( ) N ( ) Has suicide plan? Y ( ) N( )
7. Safety
Seatbelts ( ) helmets ( ) member of fraternity/gang ( )
Carry weapon for protection ( ) presence of firearms at home ( )
Others: ___________________
REVIEW OF SYSTEMS
General
Weakness ( ) fatigue ( )
Skin
HEENT
Stiffness ( )
Breasts
Respiratory
Hemoptysis ( ) dyspnea ( )
Cardiovascular
Gastrointestinal
Peripheral Vascular
color change in fingertips/toes during cold weather ( ) Swelling with redness or tenderness ( )
Urinary
Neurologic
Increased irritability ( )
Hematologic
Endocrine
Convulsions ( )
Reproductive (adolescents)
PHYSICAL EXAMINATION
I. GENERAL SURVEY
A. Weight ____________ height _____________
B. Nutritional Status Poor ( ) Fair ( ) Excellent ( )
C. Respiratory distress + ( ) -( ) cyanosis ( )
D. Level of Consciousness alert ( ) drowsy ( ) lethargic ( )
E. Type of cry or voice
F. State of hydration (ask about urine output) _____
Skin turgor: poor ( ) good ( )
Capillary refill poor ( ) good ( )
G. Posture and Gait ___________________________
Eyes
Strabismus ( ) slanting of palpebral fissures ( ) ptosis ( )
Visual tracking ( ) conjunctiva: pale ( ) normal ( )
Icteric sclera ( ) PERLA ( ) red reflex ( )
Ears
Position __________ deformities ( ) discharges ( ) __________
Tympanic membrane __________
Nose
Patent ( ) nasal flaring ( ) discharge ( ) nasal septum: midline ( ) deviated ( )
Polyps ( ) Nasal mucosal color __________ sinus tenderness ( )
Mouth and Throat
Fissures ( )
V. NECK
Tracheal position: midline ( ) deviated ( ) __________
Cysts ( ) Nodes ( )
Nuchal rigidity ( )
VIII. Abdomen
A. Inspection
1. Shape protruberant ( ) scaphoid ( )
2. Umbilicus: moist ( ) dry ( ) foul-smelling ( ) discharge ( )
3. Hernias ( )
4. Muscular integrity: poor ( ) good ( )
B. Auscultation
1. Bowel sounds: active ( ) hypoactive ( )
C. Percussion: tympanic ( ) dull ( )
D. Palpation: rebound tenderness ( ) hard-board like ( ) masses ( )
IX. GUT
Male
Female
Discharge ( )
X. MUSCULOSKELETAL
A. Back
Sacral dimple ( ) kyphosis ( ) lordosis ( ) scoliosis ( )
B. Joints
Limitation in movement ( ) swelling ( ) tenderness ( )
C. Extremities
Deformity ( ) symmetrical ( ) edema ( ) clubbing ( )
D. Hips (use ortolani’s or barlow’s maneuver)
Dislocation ( ) normal ( )
E. Gait
In toeing ( ) out toeing ( ) bow-legged ( ) knock knees ( ) limping ( )
XI. NEUOLOGIC
A. Cranial Nerves
B. Motor:
Paresis ( ) paralysis ( ) spastic ( ) rigid ( ) flaccid ( )
Clonus ( ) carpopedal spasm ( ) tics ( ) tremors ( )
Romberg’s sign ( )
C. Reflexes intact hyperreactive hyporeactive
DTR (biceps, triceps, radial, knee, ankle) ( ) ( ) ( )
Cremasteric ( ) ( ) ( )
Primitive (Moro, rooting, sucking ( ) ( ) ( )
Fencing, babinsky, etc)
D. Sensory ( ) ( ) ( )
E. Cerebellar signs
Incoordination ( ) ataxia ( ) intention tremor ( ) past point ( )
Dysdiachokinesia ( ) nystagmus ( )