General data:
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Name:_______________________________
Age:______ Sex:______ Date of Birth:______
Nationality:__________
Address__________________
# of admission____
present hospital admission______________
Date of admission__________
Time of admission__________
Informant___________(___%reliability)
Chief Complaint:_____________________
HPI:
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Past Medical History
Past illness:
________________________________________________________
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Birth History:
Age of mother @ time of birth: _____
OB score: G___P___(__-__-__-__)
Assisted by:________
Mode of delivery: (NSD__, CS__)
Place of delivery: ___________
Umbilical cord was cut by: (eg. Sterile Scissors)_____
Birth weight: ___________
Vitamin K given?
Prenatal Hx:
Prenatal check ups (how often and where)
________________________________________________________
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Medications/vitamis given:
________________________________________________________
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Medical conditions/illnesses during pregnancy:
*UTI, HPN, preeclampsia, vaginal bleeding, preterm labor
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Smoker:____________
Alcohol drinker:________
Exposure to radiation during pregnancy:
Yes____ No____
Neonatal Hx:
 __Good suck
 __Good cry
 __Jaundice
 __Cyanosis
 __Respiratory problem___________________
 __Sepsis
 __Congenital defects____________________
Nutritional Hx:
 Breast Fed(since_______upto__________)
 Milk formulas___________ ratio________
 Complimentary feeding with (ex lugaw)_____started
at______months
 Table food was introduced at___________
 Present diet:
________________________________________________
________________________________________________
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GD:
Smiles____________ months
Rolls over ____________ months
Sits with support ____________ months
Holds bottle ____________ months
Sits without support ____________ months
st
Says papa/mama 1 word ____________ months
Stands with support ____________ months
Walks alone ____________ months
Feed self with spoon ____________ months
Runs well ____________ months
Enters kindergarten ____________ months
Enters elementary ____________ months
Immunizations:
BCG _______dose/s
Heap B _______dose/s
DPT _______dose/s
OPV _______dose/s
Measles _______dose/s
MMR _______dose/s
Hib _______dose/s

Family Hx
Paternal Hx
 Asthma
 DM
 HPN
 Blood dyscrasia
 Heart dse
 Cancer
 PTB
 Allergy________

Maternal Hx
 Asthma
 DM
 HPN
 Blood dyscrasia
 Heart dse
 Cancer
 PTB
 Allergy________

Personal and social Hx

Order in the family:_________

Father
Name:_____________________________________
Age:_____________ Occupation________________

Mother
Name:_____________________________________
Age:_____________ Occupation________________

Type of House ______________________________

Number of room ___________________________
Source of drinking water _____________________

ROS
Integumentary: [ ] pruritus
CNS: [ ] headache, [ ] seizure
CRS: [ ] cough,[ ] colds ,[ ] DOB ,[ ] Chest Pain
GIT: [ ] vomiting ,[ ] abdominal pain ,[ ] diarrhea ,
[ ] constipation
GUT: [ } oliguria, [ ] dysuria, [ ] hematuria
Hematologic system: [ ] epistaxis, [ ] gumbleeding,
[ ] easy bruisability
MSS: [ ] myalgia [ ] arthalgia
Endocrine: [ ] loss of appetite , [ ] weight loss ,
[ ] sweating, [ ] fever
PE o CN V _____________(CR)
Gen. Survey: o CN VII_____________(FS)
 Awake
 Conscious Ears:
 Febrile  Discharges
 Afebrile  malformation (low set)
 Weak looking  deformities CN VIII______________(hear)
 Cordiorespiratory distress
Vital signs: Nose:
Temp._______  Discharges
HR_________  size and shape
RR_________  nasal obstruction
BP_________  nasal flaring
Anthropometric measurements  patent nostrils
Height __________  Able to smell (CN II)
Weight _________
HC ____________ Mouth
CC ____________  Epstein pearls
AC ___________  prominent tounge
Skin  tonsillopharyngeal congestion
 Bruises  hypersalivation palate
 Petechiae  cleft palate
 Jaundice  cleft lip
 Pallor  oral thrush
 Cyanosis  ulcers in the lips
 Jaundice  sucking reflex CN IX/X__________Gag Reflex
 Warm to touch  CN XII ________ tongue deviation
 Good skin turgor
 Plethora
 Vernix caseosa
 Lanugo
 Dry skin Neck
 Mongolian spots  Cervical lymphadenopathy
 Capillary hemangiomas  Webbing of the neck
 Milia  masses tonic neck reflex
 Malaria  Supple neck
 Erythema toxicum  nuchal rigidity
 Brudzinski sign
HEENT:  CN XI ___________shoulder shrug
 Distribution of hair
 Cephallohematoma Chest and lungs
 Caput succedaneum  Symmetrical chest expansion
 Subgaleal hemorrhages  Retractions
 Patent fontanelles  rales
o Anterior  wheezes
o Posterior  fractures (clavicles, crepitus, bruising and tenderness)
o Size  AP dm (increased/decreased)
o Sunken  apneic episodes
o Bulging  expiratory grunting
 Sutures (widened/overlapping)  breast budding
 Rooting reflex  supernumerary nipples
 Micro/microcephally
Heart
Eyes  Precordium (dynamic__,adynamic__)
 Subconjunctival hemorrhages  PMI___ ICS LMCL__ Murmur
 Cornea (tear/clouding) o Grade
 Epicanthal folds o Location
 Eye movement (coordinated/uncoordinated) o soft blowing
 Sclera (Icteric/unicteric) o rough
 Palpebral conjunctiva (pink__,pale__) o systolic
 CN exam: o diastolic
o CN II_____ (ERTL, 2-3MM) o radiation to
o CN III/IV/VI:________(FO)  Heart beat
 o Rate (normal/ abnormal) ________________________________________________________
o Rhythm (regula/irregular) ____

Abdomen
 Globular Infants/Children
 Flat
Eye opening 4 Spontaneous
 Normoactive bowel sounds
 Soft 3 To voice
 tender 2 To pain
 organomegaly 1 None
 abdominal distension
 abdominal masses Verbal 5 Alert, normal vocalization
 umbilical cord 4 Cries but consolable
3 Persistently irritable

Genitalia and anus 2 Restless, agitated, moaning

 Grossly male__, female__ 1 None
 Male Motor response 6 Spontaneous, purposeful
o Glans
o Opening 5 Localizes pain
o Prepuce 4 Withdraws
o shaft 3 Abnormal flexion
o testis (descended__, undescended__)
2 Abnormal extension
 Female 1 None
o labia
o clitoris I Smell
o hymental tags II Visual acuity, visual fields, and ocular fundi
II, III Pupillary reactions
Extremities III, IV, VI Extraocular movements
V Corneal reflexes, facial sensation, and jaw movements
 gross deformities VII Facial movements
 spine curvature VIII Hearing
 edema IX, X Swallowing and rise of the palate, gag reflex
 clubbing V, VII, X, XII Voice and speech
 cyanosis XI Shoulder and neck movements
 pulses: full and equal pulses XII Tongue symmetry and position
 CRT
 palmar grasp
 babinski
 Achilles tendon reflex
 moro kernigs
 biceps reflex
 motor_______ grade ___/___
 sensory: withdraws to pain.

Salient/Striking Features:
________________________________________________________
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________________________________________________________ PULSE RATE
____________________________________________ AGE LOWER LIMITS AVERAGE UPPER LIMITS
OF NORMAL OF NORMAL
Impression: NEWBORN 70/min 125/min 190/min
________________________________________________________ 1 – 11 MONTHS 80 120 160
________________________________________________________ 2 Y/O 80 110 130
________________________________________ 4 Y/O 80 100 120
6 Y/O 75 100 115
Differential Dx 8 Y/O 70 90 110
________________________________________________________ 10 Y/O 70 90 110
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________________________________________________________ RESPIRATORY RATE
AGE NORMAL RATE
< 2MONTHS < 60 / min
2 – 12 MONTHS <50
1 – 5 Y/O < 40
6 – 8 Y/O < 30

CEPHALOCAUDAL PATTERN
• 1 mo – regards
• 2 mos – smiles
• 3 mos – turns head
• 4 mos – holds head
• 5 mos – rolls over
• 6 mos – transfers objects
• 7 mos – sits briefly
• 8 mos – creeps
• 9 mos – pulls up
• 10 mos – cruises
• 11 mos – walks w/ support
• 12 mos – stands alone
GROSS MOTOR
 3 months – good head control
 5 months – roll over
 6 months – sit w/ support
 8 months – sit w/o support
 9 months – pulls to stand holding on
 15 months – walks alone
 24 months – runs well, walk up stairs 1 step at a time
 36 months – ridesa trike, stand on 1 foot
 48 months – hopon 1 foot, climbs well
 60 months – skips
FINE MOTOR
 3 mos – handsopen,grasps
 4 mos – reachesfor objects
 5 mos – transfers objects
 6 mos – holdsbottles
 9 mos – pincer grasp
 12 mos – turns pages of book
 13 mos – scribblespontaneously
 2yrs – make strokes,tower of7 cubes
 3 yrs – copy circle,tower of 10cubes
 31/2 yrs – copy cross
 4 yrs – copy square,draws man w/2-4 body parts
 5 yrs – copy triangle
 6 yrs – copy diamond
 9 yrs – copy cylinder
RECEPTIVE LANGUAGE
 1 mo – startles, alert to sound
 4 mos – turns to noise & voice
 7 mos –respond to name
 9 mos – responds to word “no”
 11 mos – follows 1-step commands w/ gestures
 12 mos – follows 1-step commands w/o gestures
 18 mos – identifies 1 or more body parts
 24 mos – follow 2-step commands
 36 mos – identifies action in pictures
 48 mos – knows 4 colors
 60 mos – follows 3-step commands
 6 mos – respond playfully to mirror
 9 mos – object permanence
 12 mos – understand spatial relationship
 18 mos – understands cause & effect
 24 mos – categorizes similarities
 36 mos – knows full name
 48 mos – knows colors or any letters
PERSONAL DEVELOPMENT
 3 mos – opens mouth expectantly
 6 mos – holds bottle, finger feeds,feeds self cracker
 12 mos – drinks well from cup, beginsto hold spoon
 18 mos – feeds self w/ spoon
 2 yrs – express need to go to bathroom,cooperates in
dressing
 3 yrs –puts on shirt & shorts, dry by night, uses fork to
pierce
 4 yrs –dresses w/o supervision,brush teeth w/ assistance
 5 yrs –ties shoelaces
SOCIAL DEVELOPMENT
 3 mos – smiles responsively
 6 mos – imitates actions
 9 mos – plays patty cake,peaks a boo
 12 mos – comes when called by name
 18 mos – follows directions related to routines
 2 yrs – parallel play
 3 yrs – likes to play make believe,demonstrates caution
 4 yrs – responds to instructions, imitatestasks
 5 yrs – plays games w/ simple rules (tag, hide-and-seek)
 6 yrs – plays board games, domestic role playing

EXPRESSIVE LANGUAGE
 3 mos – vocalizes & coos
 6 mos – monosyllabic babbles
 8 mos – says dada,mama nonspecifically
st
 10 mos – 1 words other than mama,dada
st
 12 mos – speaks 1 real word
 15mos – jargons
 2 yrs – 2-word phrases
 3 yrs – 3-word phrases
 4 yrs – tells a story, speech 100% intelligible
 5 yrs – uses past tense of eat,run,go
 6 yrs – repeats sentence of 10 syllables, names 4 colors

COGNITIVE
 NB – identify mother’s voice & smell
 3 mos – reach for dangling ring