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I.

GENERAL DATA
NAME RELIGION
AGE ADDRESS
DOBirth # of ADM.
SEX SOURCE & RELIABILITY
RACE
II. CHIEF COMPLAINT
III. HISTORY OF PRESENT ILLNESS
ONSET
LOCATION
DURATION
CHARACTERISTICS
ASSOCIATED SYMPTOMS
AGGRAVATING FACTORS
RELIEVING FACTORS/ MEDS
TIMING
SEVERITY (affects ADLs)
CONSULTATIONS/ LABS

IV. REVIEW OF SYSTEMS


GENERAL Salivation Pubertal: Mental deterioration
Weight change Sore throat Menstrual period Personality changes
Appetite CARDIOVASCULAR Onset Memory loss
Activity level Orthopnea Frequency Eating problem
Delay in growth Cyanosis Regularity School failures
Fatigue Pain Mood changes
CUTANEOUS
Fainting spells LMP Temper outburst
Rashes
Hallucinations
Pigmentation RESPIRATORY ENDOCRINE
Hair loss Chest pain Breast asymmetry MUSCULOSKELETAL
Acne Cough Breast pain Bone pain
Pruritus Dyspnea Breast discharge Myalgia
Cold/ heat intolerance Arthralgia
HEENT GUT
Polyuria Swelling
Headaches Color of urine
Polydipsia Limited motion
Dizziness Burning
Polyphagia Stiffness
Visual difficulty Frequency
Limping
Lacrimation Discharge NERVOUS/ BEHAVIORAL
Hearing Enuresis Tremors HEMATOPOIETIC
Discharges Edema Sleep problems Pallor
Epistaxis Prepubertal: Convulsions Bleeding
Toothache Discharge and itching Weakness Bruising

V. PERSONAL HISTORY

GESTATIONAL HISTORY
Who attended
Age of mother
Where
OB score
Birth weight
Illness
NEONATAL HISTORY
Meds taken
APGAR
Vaccinations
Jaundice
Duration of pregnancy
Convulsions
BIRTH
Cyanosis
Term?
Feeding difficulty
NSVD vs CS (indication)
Congenital birth injury
VI. FEEDING HISTORY
CHILDHOOD / ADOLESCENT (>2yo)
INFANCY (<2yo)
Appetite
BF vs formula (brand)
Usual food intake
Pure vs mixed
Amount per day
Amount
Five basic food groups
Frequency per day
Preferences
Complementary food:
Intolerance
Age when started
MV and supplements
Foods introduced
ACI
Food intolerance
RENI
MV and supplements (dose & frequency)
Compute ACI and RENI

VII. DEVELOPMENT / BEHAVIORAL

1-5 years old 6-11 years old


Safety
MMDST School performance
Suicide
Dental eruptions Tanner stage
Sexuality (initiation and orientation)
Enuresis
10-20 years old Friends/ family
Encopresis
Homes Image
Tantrums
Education/ School Recreation
Head banging
Abuse Spirituality
Phobias
Drugs Threats and violence

VIII. PAST ILLNESSES


State of health
Measles, mumps, varicella
Father's age
Hospitalizations
Father's occupation
When
State of health
Where
Siblings
Surgeries
Ages
Trauma
State of health
Allergy
TB
Eczema
Asthma
Asthma
HTN
Tuberculin test
Heart diseases
Immunizations
Allergy
IX. FAMILY HISTORY Epilepsy
Mother's age Cancer
Mother's occupation MR

X. SOCIOECONOMIC
Place and nature of home
Number of persons
Family members who work

XI. ENVIRONMENTAL
Exposure to smoking (duration)
Pollutants
Garbage disposal
Water source