CLINICAL EVALUATION - Pediatrics

Date: _______________
General Data
Name:

Sex:

Birthday:

Age:

Birthplace:

Nationality:

Address:

Religion:

Informant:

Relation:

Reliability:
Source of referral:
Chief Complaint: ______________________________
History of Present Illness
Onset:
Location:
Duration:
Character:
Aggravating factors:
Alleviating factors:
Radiation:
Timing:
Associated manifestation/s:
Additional information
Notes:

Informants thoughts and feeling about the illness:

How did it affect daily living?

Treatment/Medications
(name, dose, route, frequency of use):

Allergies:
Food:
Environmental factors:

Drugs:
Insects:

Past History
Pregnancy: Age: ____, G__P__Problems in pregnancy?
Tobacco and alcohol use?
Birth:
pre-, post-, term (__ wks AOG)
normal? CS?
Good cry? Spontaneous respiration?
Meconium staining? Cord coiling?
BW: __kg; BL: __cm; HC: __cm; CC: __cm; AC:__cm
Neonatal:
Jaundice? Cyanosis?
Room-in?
Other complications during 1st month?
Immunizations (dose, date)
BCG
Measles vaccine
MMR
Rotavirus
Illnesses:
Measles?
Chickenpox?
Hospitalizations? (date)

DTaP-Hib-Polio
Hep B
OPV
PCV

Mumps?
Others: _________

Nutritional
Breastfed until_____Intake of solid_____Mixed_____
Current appetite:
Growth & Devt
Sat up _____Crawled_____Stood up_____Walked_____
Babble_____1st word/s_____
1st tooth eruption_____

Family History (member, age of diagnosis, date of death)

Diabetes?
Hypertension?
Asthma?
Allergies?
Genetic diseases?
TB?
Childhood diseases?
Others: _________

Social and Environmental History

No. of Siblings:
Mother

Occupation:

Age:

Father

Occupation:

Age:

Accidents?
Current household?
Home safety? (describe place)
Crowded area?
Ventilation?
Pets?
Environmental exposures?
Usual day, Hobbies:

Notes:

!
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PHYSICAL EXAMINATION
General:
VS, Anthropometric:
BP:
HR:
RR:
Wt:
Ht:
BMI:
Skin
Head
Eyes
Ears
Nose
Throat/Mouth
Neck
Lymph nodes
Lungs
CV
Abdomen
Musculoskeletal
Neurologic
!

Temp:
HC:

ROS: (include dates)

General
Weight loss or gain
Fatigue
Fever or chills
Weakness
Trouble sleeping
Skin
Rashes
Lumps
Itching
Dryness
Color changes
Hair and nail changes
Head
Headache
Head injury
Ears
Infections
Decreased hearing
Ringing in ears
Earache
Drainage
Eyes
Vision Loss/Changes
Glasses or contacts
Pain
Redness
Blurry or double vision
Last eye exam
Nose
Stuffiness
Discharge
Itching
Nosebleeds
Runny nose
Throat/Mouth
Bleeding
Dental caries
Freq. of tooth brushing
Sore tongue
Dry mouth
Sore throat
Thrush
Non-healing sores
Neck
Lumps
Swollen glands
Pain
Stiffness
Respiratory
Cough
Sputum
Coughing up blood
Shortness of breath
Wheezing
Painful breathing

Cardiovascular
Chest pain or discomfort
Tightness
Palpitations
SOB with activity
Difficulty breathing lying
down
Sudden awakening from
sleep with SOB
Gastrointestinal
Swallowing difficulties
Heartburn
Change in appetite
Nausea
Change in bowel habits
Rectal bleeding
Constipation
Diarrhea
Yellow eyes or skin
Toilet trained
Urinary
Frequency
Urgency
Burning or pain
Blood in urine
Incontinence
Musculoskeletal
Muscle or joint pain
Stiffness
Trauma
Neurologic
Dizziness
Fainting
Seizures
Weakness
Tingling
Hematologic
Ease of bruising
Ease of bleeding
Endocrine
Head or cold intolerance
Sweating
Frequent urination
Thirst
Change in appetite
Psychiatric
Happy? Sad?
Cries easily
Independent
Tantrums