Pediatric History

Identifying Data: Patient's name, age, sex; significant medical conditions,
informant (parent).

Chief Compliant (CC): Reason that the child is seeking medical care and
duration of the symptom.

History of Present Illness (HPI): Describe the course of the patient's illness,
including when and how it began, character of the symptoms; aggravating or
alleviating factors; pertinent positives and negatives, past diagnostic testing.

Past Medical History (PMH): Medical problems, hospitalizations, operations;
asthma, diabetes.

Perinatal History: Gestational age at birth, obstetrical complications, type of
delivery, birth weight, Apgar scores, complications (eg, infection, jaundice),
length of hospital stay.

Medications: Names and dosages.

Nutrition: Type of diet, amount taken each feed, change in feeding habits.

Developmental History: Age at attainment of important milestones (walking,
talking, self-care). Relationships with siblings, peers, adults. School grade and
performance, behavioral problems.

Immunizations: Up-to-date?
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder;
diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, smoking.

Social History: Family situation, alcohol, smoking, drugs, sexual activity.
Parental level of education. Safety: Child car seats, smoke detectors, bicycle
helmets.

Review of Systems (ROS)
General: Overall health, weight loss, behavioral changes, fever, fatigue. Skin: Rashes, moles, bruising, lumps/bumps, nail/hair changes. Eyes: Visual problems, eye pain.
Ear, nose, throat: Frequency of colds, pharyngitis, otitis media. Lungs: Cough, shortness of breath, wheezing. Cardiovascular: Chest pain, murmurs, syncope.
Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdominal pain, constipation, blood in stools.
Genitourinary: Dysuria, hematuria, polyuria, vaginal discharge, STDs. Musculoskeletal: Weakness, joint pain, gait abnormalities, scoliosis. Neurological: Headache, seizures.
Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses duration, amount of flow.
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