Escolar Documentos
Profissional Documentos
Cultura Documentos
I. VITAL INFORMATION Name of Child: Sex: Date of Birth: Age: Address: Name of Mother: Educational Attainment: Occupation: Name of Father: Educational Attainment: Occupation: Approximate Income of the Family: Name of Informant: Relationship with child:
II. PERSONAL HISTORY A. Prenatal Mothers general health ( Did the mother had toxemias, analgesia or radiation therapy, viral or other infections?): Medications taken during pregnancy: Pain, bleeding, threatened abortion: None: Yes: Specify: B. Birth Duration and circumstances of labor: Analgesia Used: Delivery: Home: Complications: Birth Weight: AOG: C. Neonatal: Feeble: Resuscitated: Convulsions: Pallor:
Hospital:
Type:
III. FAMILIAL HISTORY Birth Order of the Child: Number of living siblings: Serious diseases/ illness of siblings: Congenital diseases among siblings: Death of siblings: Heredo-familial diseases: Total Number of Siblings: Type of housing: Cause of death:
IV.PAST MEDICAL HISTORY Number of Past Hospitalizations: Date of last confinement: Reason for hospitalization: Number of days of hospitalization: V. NUTRITIONAL HISTORY Feeding (check and specify) Bottlefeed: Supplementary feeding: Vitamins: Food likes: Dislikes: Beliefs and fallacies: Breastfeed: Type: Amount: Mixed: ___________ Age started: When: Where:
VI.EATING PATTERNS (For older children) Usual Foods Taken Breakfast Time of Day
Lunch
Supper
Snacks
VII. REST AND SLEEP Usual bedtime: Naps: Bedtime rituals: Problems with sleep: Usual remedy: Total number of hours of sleep: VIII. ELIMINATION PATTERNS A. Bowel Elimination Frequency: Problems: Usual Remedy: B. Urinary Remedy Frequency: Problems: Usual Remedy: IX. IMMUNIZATION STATUS Rising time:
1ST dose age OPV DTP MMR BCG Hepa A Hepa B CT Others (specify):
2nd dose
3rd dose
booster 1
Eyes:
Ears:
Nose:
Mouth:
Neck:
Chest:
Back:
Abdomen:
Extremities Upper:
Lower: Genito-anal:
Skin:
Pulse:
Respiratory Rate:
BP:
C.Sensory Development
E.Psychosexual Development
F.Spiritual Development
G.Cognitive/Intellectual Development
H.Language/Speech Development
B.
Activities
C.
Immunization
D.
Safety
E.
Others