Date and Time of Interview: Informant and Reliability:: Pediatrics History Taking and Pe Form (Based From Navarro)
Date and Time of Interview: Informant and Reliability:: Pediatrics History Taking and Pe Form (Based From Navarro)
Date and Time of Interview: Informant and Reliability:: Pediatrics History Taking and Pe Form (Based From Navarro)
I. IDENTIFYING DATA
Name of Patient
Age Sex
Birthdate Birthplace
Religion Ethnicity
Current address
# of hospital
admissions and
institution
*Parts A, B, C should only be asked if patient is <2 yrs old or in > 2 yrs old if the chief complaint and HPI is
related to the illness.
A. GESTATIONAL HISTORY
B. BIRTH HISTORY
C. NEONATAL HISTORTY
D. FEEDING HISTORY
i. INFANTS (<2 yrs old)
Type of Feeding
If BF, duration per breast,
frequency per day
If formula feeding/mixed
feeding, formula milk type,
dilution, frequency, bottle fed or
cup fed?, reason for formula
feeding/mixed feeding
Complementary foods: age,
usual food, freq and amount
ii. Children and Adolescents
E. DEVELOPMENTAL/BEHAVIORAL HISTORY
i. Milestones
School Performance
Sexual development
(Tanner Maturity
Rating)
Home
Education
Eating behavior/habits
Activity
Drugs
Sexual
Suicidal ideations
SMR (if female, include menstrual
hx)
F. PAST ILLNESSES
Ask for:
A. Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and
asthma, epilepsy
Living circumstances
Place Nature of Dwelling
# of persons living in (Describe house,
the house #rooms, windows,
toilet)
Economic circumstances
Working members of Source of funds
the family
VIII. ENVIRONMENTAL HISTORY
Electricity
Water (drinking and utilities)
Cigarette smoking exposures
Fumes
Garbage disposal
Pets
Skin and Lymph Nodes: (-) itchiness, (-) excessive dryness or sweating, (-) cyanosis, (-) pallor, (-)
Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-) excessive lacrimation, (-)
Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge, (-) mass, (-) cerumen
Nose and Sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-)
Mouth and Throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-)
hoarseness, (-) mouth breathing, (-) snoring, (-) dyspnea, (-) caries
Respiratory: (-) pleuritic chest pain, (-) cough, (-) sputum production, (-) hemoptysis, (-)
audible wheezing
Cardiovascular: (-) palpitations, (-) syncope, (-) easy fatigability
Gastrointestinal:, (-) nausea, (-) dysphagia, (-) diarrhea (caused by suppository), (-) constipation,
(-) hematemesis, (-) melena, (-) hematochezia, (-) regurgitation, (-) vomiting, (-) epigastric pain
Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-)
Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) intermittent
Nervous: (-) headache, (-) vertigo, (-) syncope, (-) loss of consciousness, (-) focal weakness, (-)
paralysis, (-) numbness, (-) paresthesia, (-) speech disorder, (-) loss of memory, (-) confusion