GENERAL DATA

Name: ____________________________________________________________
Sex: ______ Age: _______ Weight: _________ kg
Height: ________ cm
Birthday: _________________________ Birth Place: _____________________
Address: __________________________________________________________
Citizenship: ( ) Filipino ( ) Others: ____________________________________
Religion: ( ) RC ( ) INC ( ) Born Again Others: _______________________
Date of Admission: ___________________ Time of Admission: ________ AM / PM
Informant: _______________________________ Reliability: _________________
CHIEF COMPLAINT: ________________________________________________
HISTORY OF PRESENT ILLNESS
Please indicate the Onset, Provocation/Palliation, Quality of Pain, Region and Radiation, Severity,
Time (History), Aggravating/Alleviating Factors, Associated Symptoms, Attributions/Adaptations

REVIEW OF SYSTEMS
Constitutional: () fever, () anorexia, () weight loss
HEENT: () ear pain, () aural discharge, () epistaxis, () sore throat
Cardiovascular: () cyanosis, () palpitations, () orthopnea, () easy fatigability
Respiratory: () dyspnea, () hemoptysis
Gastrointestinal: () vomiting, () diarrhea, () constipation
Genitourinary: () discharge, () oliguria, () dysuria
Endocrine: () heat/cold intolerance, () polyuria, () polydipsia, () polyphagia
Musculoskeletal: () joint pain, () muscle pain
Hematologic: () pallor, () bleeding manifestations, () easy bruising
Neurologic: () tremors, () increase in sleeping time
BIRTH AND MATERNAL HISTORY
Maternal:
Age of the mother: _______ OB Score: G P ( - - - )
( ) smoker ( ) alcoholic beverage drinker ( ) illicit drug use: _______________
Prenatal Check-up: total of ___________ PNCUs
Start: _____________________ AOG Attended by: _________________________
Last: ______________________ AOG Attended by: ________________________
Prenatal Medications: ________________________________________________
UTZ: _________ AOG: ______________
_________ AOG: ______________
Maternal Illnesses During Pregnancy: ____________________________________
Labs done/Meds taken: _______________________________________________
Date
Sex AOG Manner
Place
Attendant Complications
G1
G2
G3
G4
G5

Birth:
Delivered: _____ AOG via ( ) NSD/( ) CS by _____________ in _____________
Birth weight: _______ kg
( ) cord coil
( ) meconium stained amniotic fluid
( ) Vit K ( ) BCG ( ) NBS: Result: __________________________________
Complications: _____________________________ Sent home after: _____ days
IMMUNIZATION HISTORY
( ) BCG
( ) Rotavirus
( ) DPT 1 ( ) DPT 2 ( ) DPT 3
( ) PCV/PPV
( ) OPV 1 ( ) OPV 2 ( ) OPV 3
( ) Influenza
( ) Hep B 1 ( ) Hep B 2 ( ) Hep B 3
( ) Varicella
( ) Measles
( ) MMR
( ) Hep A
( ) HiB
( ) HPV
Given in: ________________ Complications: ______________________________
NUTRITIONAL AND FEEDING HISTORY
( ) Breastfed Duration: _________________ Age Weaned: ________________
( ) Milk Formula: _________________ Dilution: ______ ______oz Q _____ hrs
Started complimentary feeding: _______ months
24-hour food recall:
Breakfast: _________________________________________________________
Merienda: _________________________________________________________
Lunch: ____________________________________________________________
Merienda: _________________________________________________________
Dinner: ___________________________________________________________
Food Preferences: __________________________________________________
GROWTH AND DEVELOPMENTAL HISTORY
NORMAL ACTUAL
NORMAL ACTUAL
MILESTONES
MILESTONES
Regards
1
Drinks from cup
9 - 17
Smiles
2
Toilet-trained
14 - 48
Turns head
3
Feeds self
18 36
Holds head
4
Undresses
20 - 36
Rolls over
5
Vertical/circular strokes
2 yrs
Transfers object
6
Copies circle
3 yrs
Sits briefly
7
Writes name
Creeps
8
Says mama/dada
5 14
Pulls up
9
2-3 word sentences
2 yrs
Cruises
10
Knows name & gender
3 yrs
Stands alone
12
Asks questions
3 yrs
Walks alone
15
Counts
Runs
18
Says songs/tells stories
4 yrs
Up and down stairs 2 yrs
Asks meanings of words
5 yrs
Schooling: ____________________ Performance: ( ) good:________ ( ) poor
PAST MEDICAL HISTORY
( ) Measles ( ) Chickenpox ( ) Mumps ( ) Asthma
( ) Previous Hospitalizations: __________________________________________
( ) Surgical Procedures: ___________________________ When? ____________
Allergies: ( ) Drug: __________________
( ) Food: ____________________
Maintenance Medications: _____________________________________________
FAMILY HISTORY
(indicate whether maternal or paternal side)

Similar illness in the family: ___________________________________________

( ) PTB
( ) seizure
( ) bronchial asthma
( ) hypertension
( ) cancer
( ) diabetes mellitus
( ) heart disease
( ) kidney diseases
Others: ____________________________________________________________
SOCIAL AND ENVIRONMENTAL HISTORY
House: ________ storey ( ) concrete ( ) wooden
Ventilation: ________________ Lighting: __________________
No. of household members: _________
Drinking water: ___________________________ If tap, boiled? ( ) Yes ( ) No
Garbage Disposal: _______________ _____ x/week Toilet: ________________
( ) History of travel: ____________________________ When? ______________
( ) Exposure to smoking ( ) Nearby Dumpsite ( ) Nearby factories
( ) Pets: _________________________ Stay inside the house? ( ) Yes ( ) No
JI Robert C. Rea | 2016

PSYCHOSOCIAL ASSESSMENT FOR ADOLESCENTS (HEADSSFIRST)

HOME. Space, privacy, frequent geographic moves, neighborhood.

EDUCATION/SCHOOL. Frequent school changes, repetition of a grade/ in each

subject, teachers reports, vocational goals, after-school educational clubs
(language, speech, math, etc.), learning disabilities
ABUSE. Physical, sexual, emotional, verbal abuse; parental discipline

DRUGS. Tobacco, alcohol, marijuana, inhalants, club drugs, rave parties, others.
Drug of choice, age at initiation, frequency, mode of intake, rituals, alone or with
peers, quit methods, and number of attempts
SAFETY. Seat belts, helmets, sports safety measures, hazardous activities, driving
while intoxicated

SEXUALITY/SEXUAL IDENTITY. Reproductive health (use of contraceptives,

presence of sexually transmitted infections, feelings, pregnancy)

FAMILY AND FRIENDS. Family: Family constellation, genogram, single/

married/separated/divorced/blended family, family occupations and shifts; history of
addiction in 1st- and 2nd-degree relatives, parental attitude toward alcohol and
drugs, parental rules; chronically ill physically or mentally challenged parent.
Friends: peer cliques and configuration (preppies, jocks, nerds, computer
geeks, cheerleaders), gang or cult affiliation
IMAGE. Height and weight perceptions, body musculature and physique,
appearance (including dress, jewelry, tattoos, body piercing as fashion trends or
other statement)
RECREATION. Sleep, exercise, organized or unstructured sports, recreational
activities (television, video games, computer games, Internet and chat rooms, church
or community youth group activities [e.g., Boy/Girl Scouts; Big Brother/Sister groups,
campus groups]). How many hours per day, days per week involved?
SPIRITUALITY AND CONNECTEDNESS. Use HOPE* or FICA acronym;
adherence, rituals, occult practices, community service or involvement
HOPE, hope or security for the future; organized religion; personal spirituality and practices;
effects on medical care and end of life issues.

FICA, faith beliefs; importance and influence of faith; community support.

THREATS AND VIOLENCE. Self-harm or harm to others, running away, cruelty to

animals, guns, fights, arrests, stealing, fire setting, fights in school

JI Robert C. Rea | 2016