Use the following format while taking history from a child/ baby or neonate in Pediatrics department.
NAME: AGE SEX
ADDRESS ADMITED FROM
ON ( DATE )
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
SYMPTOMATOLOGY.
FEVER:
ONSET.
DURATION.
INTENSITY
PATTERN
ASSOCIATED SYMPTOMS.
EXAMINE THROAT:
FEEDING:
CHANGE IN FEEDING DURING ILLNESS.
DIFFICULTY IN FEEDING.
REFUSAL TO FEEDING
VOMITING:
FREQUENCY OF VOMITING
FORCE OF VOMITING
RELATIONSHIP OF VOMITING WIH FEEDING
COLOR AND CONTENT OF VOMITUS
BOWEL HABITS:
Diarhea:
Duration of Diarhea :
Frequency:
Consistency:
Color:
Odor:
Contents of stool ( blood or mucus )
Crying:
Cry more often?
Cry less often ?
Cry is normal ?
Cough:
Duration:
Dry or wet:
Time of day
Relation with feeding?
Accompanied by wheeze of fever?
Difficult Breathing?
Age of onset?
Duration?
Relation with activity?
Relation with feeding?
Presence of cough stridor wheeze or cyanosis
Rashes:
Duration:
Site and distribution:
Type: (macular, papular,vesicular, pustular,purpuric)
Presence of itching.
Cyanosis:
Age of onset:
Duration:
Episodic or persistent:
Associated symptoms: ( respiratory distress )
Jaundice
Age of onset:
Duration:
Associated symptoms:
Lethargy and Unconciousness
Posture and Gait:
Neck holding and sitting.
Standing and walking
Usual body movements.
Involuntary movements.
Age of onset
Duration
Any relation with febrile illness
Progress since onset.
Convulsions:
Hearing:
History of Birth
Antenatal
Inquire about mother disease:
Eg.
Diabetes mellitus
Hypertension
Swelling of feet
Fits
Infections (TB , rubella )
Drug intake ( dose, duration and time of gestation)
X-rays
Natal:
Duration of gestation.
Place of delivery
Duration of labor
Mode of delivery
Complications during delivery
Postnatal
First cry (immediate or late )
Time of onset of respiration after delivery
Any resuscitation giver?
Birth weight
Birth injury
Feeding difficulty in postnatal period
Jaundice, cyanosis, fits, fever or any other symptoms during neonatal period.
Feeding history:
Time between birth and first feed:
Type of feeding ( breast or formula feeding)
Frequency of feeding ( quantity and dilution of bottle feed)
Age at which solids are started:
Current feeding practices before current illness
Any change in food intake during illness.
Immunization:
Visit to vaccination center?
Type of Vaccine?
When and given by whome?
When and given by whome?
Complete of incomplete?
Boosters.?
Developmental History:
Smile? Hold his neck? Rollover Start responding to voice Sit up with support and without support? Crawl? Start to walk with and without support Talk(single word, sentence)
Run Start feeding with hand
Indicate toilet needs
Past History:
Medical ( respiratory infections, diarrhea, fevers fits etc )
Surgical:
Family History:
Age of the mother and father?
Parent’s health (present and past)
Siblings: (age and sex, Illnesses, any deaths , still births miscarriages)
Grand parent’s health:
Inherited disorders?
Consanguinity (blood relation between parents eg. Cousin marriage, second cousin marriage)
Social History
Parent Education :
Parent’s Occupation:
Family Income:
Person living in the house:
Personal History:
Particular habits of child:
Class:
Interest in studies:
Behavior of child
Environmental history:
Size of house:
No of inhabitants
Cleanliness and general hygienic conditions
Source of drinking water