I.

General Data
Name
Date of Birth, age
Gender
Address
Source and Reliability of Inform:
II. Chief Complaint/ Presenting Problem/Reason for Seeking Care

females: breast development and nipples

sexual hair
menstruation
acne
males: development of sexual hair
voice changes
acne

III. History of Present Illness

Onset: when the problem started;
Location/timing
Duration: length of problem or episode
Character: nature
Aggravating and associated factors
Relieving factors and effect on the problem
Temporal factors
Severity of symptoms
IV. Maternal and Birth History
Prenatal:
Mothers health during pregnancy:
specific complications:
illnesses related to pregnancy:
tobacco, alcohol/ drugs taken:
attitude concerning pregnancy:
List all pregnancies(GP, FPAL)
Dates and duration of pregnancies(include miscarriages)

VI. Immunizations
dates of administration of each vaccine:
reactions to specific vaccines:
VII. Past Illnesses : Include dates and complications
Medical illnesses
Surgeries, Injuries/Accidents
Drug reactions/Allergies
Hospitalizations
Blood transfusions
VIII. Family History
Size of the family
Health and problems of other children (include deceased : date, age,
cause of death)

Natal:

IX. Personal and Social History

Home Conditions:
Living conditions,
housing,
economic status
Fathers and mothers occupations
Principal caretakers of the child
Spiritual orientation & Cultural heritage
X. Review of Systems
Skin : eczema, seborrhea, cradle cap
Eyes: vision
Ears: otitis media, hearing
Nose: snoring, mouth breathing, allergies
Teeth: dental care
Respiratory
Gastrointestinal
Cardiovascular
Genitourinary: bladder control, nocturia
Neuromuscular

Nature of labor and type of delivery

Duration
analgesia use
Complications encountered
birth order if multiple
Neonatal:
Condition of infant at birth
Apgar score
estimated age
weight
Specific problems:
Feeding
Respiratory
Jaundice
Anemia
congenital anomalies
infection
V. Feeding History
Infancy:
Method of feeding (breast, bottle combination);formula
Introduction of solid foods; age weaned from bottle/breast
Childhood
Eating habits
Present diet and appetite
VI. Developmental History
age at which developmental milestones were attained
School Age: grade
Performance
age

systolic

diastolic

birth

50-70

25-45

neonate

60-90

20-60

infant

87-105

53-66

Toddler (2yo)

95-105

53-66

School age
(7yo)

97-112

57-71

adolescent

112-128

66-80

problems
Growth: height
Weight( in sequence of ages)
Sexual dev: present status

Important diseases in the family: including ailments relevant to the

patients present condition
Pedigree chart to include heredofamiliar diseases/conditions

B. Physical Exam
General survey:
Size(age appropriate):
morphologic features:
development:
behavior:
interaction of the child:
skin color
respiration
hydration
mental status
Vital Signs
HR:
RR:
Temp:
BP:
Ht:
Wt:

Age

mean

Newborn to 3 mos
3mo to 2yo
2 yo 10 yo
>10 yo

awake rate

140

85-205

80-160

130

100-190

75-160

60-140

60-90

60-100

50-90

80
75

TEMPERATURE - 36.5-37.5 C
< 36.5 C = HYPOTHERMIA
> 37.5 C = HYPERTHERMIA
oral temperature - 33.238.2 C
for rectal - 34.437.8 C
for the tympanic cavity- 35.437.8 C
axillary - 35.537.0 C
AGE

RR PER MINUTE

NEWBORN

40-60

<1

28-38

1-3

20-24

4-6-

20-24

7-9

18-24

10-14

16-22

14-18

Sleeping rate

14-20