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This document contains a clinical history form for a pediatric patient. It includes sections for general patient data, chief complaint, history of present illness, personal history, feeding history including a sample diet, growth and developmental history, past illnesses, immunization history, family history, socioeconomic and environmental history, and a review of systems. The review of systems section contains a list of potential symptoms organized by body system and indicates whether the patient currently experiences each symptom.

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Department of Pediatrics II

CLINICAL HISTORY
I. GENERAL DATA

II. CHIEF COMPLAINT:

III. HISTORY OF PRESENT ILLNESS

III. PERSONAL HISTORY

FEEDING HISTORY

SAMPLE DIET
Breakfast
Lunch
Dinner
Snacks

GROWTH AND DEVELOPMENTAL HISTORY

PAST ILLNESSES

IV. IMMUNIZATIONS

Vaccines 1st Dose 2nd Dose 3rd Dose Booster Place

BCG
DPT
OPV
Hepatitis B
Measles
MMR
HiB
Influenza
Pneumococcal
Rotavirus
Meningococcal
Hepatitis A
Varicella
Typhoid

V. FAMILY HISTORY

VI. SOCIOECONOMIC AND ENVIRONMENTAL HISTORY

VII. REVIEW OF SYSTEMS

General (-) weight loss, (-) easy fatigability, (+) fever, (+) irritable, (-) chills, (-) dizziness,
(-) syncope, (+) loss of appetite, (+) lethargy
Integumentary (-) rashes, (-) pruritus, (-) pigmentation, (-) cyanosis, (-) jaundice, (-) pallor, (-)
dryness, (-) facial flushing
HEENT:
Head and Neck (+) headache, (-) dizziness, (-) stiffness, (-) lesions, (-) trauma, (-) swelling
Eyes (-) tearing, (-) itching, (-) redness, (-) discharge, (-) dryness
Ears (-) ear discharge, (-) hearing loss
Nose (-) colds, (-) bleeding, (-) obstruction, (-) anosmia, (-) watery discharge, (-)
congestion
Mouth and (-) soreness, (-) pain, (-) dryness, (-) gum bleeding, (-) hoarseness, (-) swallowing
Throat problem
Respiratory (-) cough, (-) sputum, (-) hemoptysis, (-) difficulty of breathing, (-) wheezing, (-)
cyanosis, (-) pain
Cardiovascular (-) chest pain, (-) palpitations, (-) dyspnea, (-) orthopnea, (-) paroxysmal
nocturnal dyspnea, (-) cyanosis, (-) syncope, (-) edema
Peripheral (-) intermittent claudication, (-) cramps, (-) edema
vascular
GIT (+) nausea, (+) vomiting, (+) heartburn, (+) anorexia, (+) no bowel movement
for 3 days, (+) diffuse abdominal pain sometime in the Right Upper Quadrant
and Epigastric Region, (-) melena, (-) hematochezia, (-) dysphagia,
GUT (-) urinary frequency, color (-) dysuria, (-) hematuria, (-) nocturia, (-) oliguria, (-)
discharge, (-) rash, (-) bleeding, (-) discharge
Musculoskeletal (-) muscle pain, (-) joint pain, (-) stiffness, (-) weakness, (-) limitation of motion,
(-) trauma
Hematological (-) polydipsia, (-) polyphagia, (-) polyuria, (-) profuse sweating
Hematological (-) anemia, (-) bleeding, (-) bruising, (-) transfusions
Nervous (-) disorientation, (-) numbness or loss of sensation, (-) prickling sensation on all
extremities, (-) seizures, (-) syncope, (-) dizziness, (-) Convulsions, (-) tremors, (-)
coordination problems, (-) sensory disturbances, (-) sleep disorder