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  • Pedia Guide

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    MarieCris
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    This document contains a general data and history form for patients seen at the Department of Pediatrics at Saint Louis University School of Medicine. It collects information about the patient's chief

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    This document contains a general data and history form for patients seen at the Department of Pediatrics at Saint Louis University School of Medicine. It collects information about the patient's chief

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato DOCX, PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    49 visualizações4 páginas

    Pedia Guide

    Enviado por

    MarieCris
    This document contains a general data and history form for patients seen at the Department of Pediatrics at Saint Louis University School of Medicine. It collects information about the patient's chief

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato DOCX, PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 4

    SAINT LOUIS UNIVERSITY Associated Manifestation: ________________________________ Drug intake: ___________________________________________

    SCHOOL OF MEDICINE Relations to ADL: _______________________________________ Radiation: _____________________________________________

    DEPARTMENT OF PEDIATRICS Exposure/Infectious disease: ______________________________ Duration of Gestation: ___________________________________

    GENERAL DATA: Consultation: __________________________________________ Prenatal Care: _______________________________________

    Name: ________________________________________________ Where & When: ________________________________________ Where: Health Center/Private OB/OPD/Other: ________________

    Age: ____ Birthday: __________ Birthplace: __________________ Medication: ___________________________________________ Associated signs and symptoms:

    Sex: ____ Nationality: _______________ Religion: _____________ Drug, Dosage: __________________________________________ Nausea: ______ Vomiting: _______ Urinary Disturbances: ______

    Classification: __________________________________________ Duration of treatment: ___________________________________ Fatigue: ______ Breast tenderness & tingling sensation: ________

    Address:_______________________________________________ Prescribed or Self Medication: _______ _____________________ Chloasma: ______ Melasma: _________ Weight Gain: _________

    Occupation: ___________________________________________ Effect of Drug: _________________________________________ Prepregnant weight: _____ Other Signs & Symptoms: _________

    Date of Admission/ Consultation: __________ # Consultation: ___ Remedies (done at home): ________________________________ Ultrasound: ____________________________________________

    Informant: __________________________ Reliability: ________% Change of Position: ______________ Diet: ___________________ Urinalysis: _____________________________________________

    CHIEF COMPLAINT: Herbal Medicine: ________________ Massage: _______________ Other Test: ____________________________________________

    ______________________________________________________ Rituals: ____________________ Religious belief: _____________ Medication: ___________________________________________

    ______________________________________________________ Effect: ________________________________________________ Vitamins/Food Supplements: ______________________________

    HISTORY OF PRESENT ILLNESS: PERSONAL HISTORY Vaccination: ___________________________________________

    Onset: ________________________________________________ **Prenatal, Birth, & Neonatal: Included only in patients <2 years Quickening: ____________________________________________
    old or if related to the illness of children > 2 years old)
    Location: ______________________________________________ Alcohol: _______________________________________________
    A. GESTATIONAL HISTORY (PRENATAL HISTORY)
    Radiation: _____________________________________________ Cigarette Smoke: _______________________________________
    Age of mother (during pregnancy):_________________________
    Duration: ______________________________________________ Toxic Chemicals: ________________________________________
    OB score: G: _____ P: ______ (T:______ P:_____ A:_____ L:_____)
    Timing/Frequency: ______________________________________ Accident: ______________________________________________
    Pregnancy: Planned/Unplanned and Wanted/Unwanted
    Quality: _______________________________________________ Trauma: ______________________________________________
    Pregnancy: With/Without Attempt of Abortion
    Quantity: ______________________________________________ Travel: ________________________________________________
    Health: ______________________________________________
    Severity: ___________________________________ (Rate 1 10) B. BIRTH (NATAL HISTORY)
    Nutrition: _____________________________________________
    Precipitating Factor:_____________________________________ AOG: Term/Preterm/Postmature: __________________________
    Infections: _____________________________________________
    Hours of Labor: _________________________________________
    Manner of Delivery: NSVD/LCCS: ___________________________ Dilution and Amount/day: ________________________________ Food likes: _____________________________________________

    Place of Delivery: _______________________________________ Bottle feeding or Cup feeding: _____________________________ Food dislikes: __________________________________________

    Person who attended Delivery: ____________________________ Complimentary Foods: ___________________________________ Feeding difficulties: _____________________________________

    Bag of Water: __________________________________________ Age introduced: ________________________________________ Multivitamins/Iron supplements: __________________________

    Birth weight: ___________________________________________ Consistency: Pureed/Soft/Lumpy/Table foods: ________________ Dosage: _______________________________________________

    APGAR Score: __________________________________________ Frequency of feeding/day: ________________________________ Frequency: ____________________________________________

    Sample Diet: E. GROWTH & DEVELOPMENTAL

    BREAKFAST LUNCH DINNER SNACK YOUNG CHILDREN (1-5 YEARS)

    TOTAL
    MIDDLE CHILDHOOD (6-11 YEARS)

    Acute Caloric Intake: ____________________________________

    RENI: _________________________________________________ ADOLESCENCE (10-20 YEARS)


    C. NEONATAL HISTORY
    Food intolerance: _______________________________________ Home: ________________________________________________
    Jaundice: ______________________________________________
    Multivitamins/Iron supplements:___________________________ Education: _____________________________________________
    Convulsions:___________________________________________
    Dosage: _______________________________________________ Eating behaviour: _______________________________________
    Haemorrhage: _________________________________________
    Frequency: ____________________________________________ Activities: _____________________________________________
    Respiratory or feeding difficulty: ___________________________
    Caregiver: Mother/Father/Grandparents/Siblings/Uncle/Aunt/ Drugs: ________________________________________________
    Congenital abnormality: __________________________________ Cousin/Household Helper/Other: __________________________
    Sexual: _______________________________________________
    Birth injury: ____________________________________________ CHILDHOOD AND ADOLESCENT (2 20 YEARS)
    Suicidal Ideations: ______________________________________
    Blood type: ____________________________________________ Appetite: Good/Picky Eater: _______________________________

    D. FEEDING HISTORY BREAKFAST SNACK AM LUNCH SNACK PM DINNER


    F. PAST ILLNESS
    INFANCY (<2 YEARS OLD)
    TOTAL Contagious disease: Measles/Varicella/Mumps/Pertusis/Other:
    Type of feeding: Breastfeeding/Formula Milk/Mix: ____________ ______________________________________________________

    Acute Caloric Intake: ____________________________________ Clinical Course: _________________________________________


    Feeding times/day: ______________________________________

    RENI: _________________________________________________ Disease/Age: ___________________________________________


    Reason (if not breastfeeding): _____________________________

    Assess if basic food group are eaten daily: ___________________ Severity: ______________________________________________
    Formula Milk Used: _____________________________________
    Complications: _________________________________________ Disease/Age: ___________________________________________ Educational Attainment: _________________________________

    Other Medical Illness: ____________________________________ Severity: ______________________________________________ Mother/Age: ___________________________________________

    Hospitalized? _______ Where: ____________________________ Complications: _________________________________________ Occupation: ___________________________________________

    Duration: ______________________________________________ IMMUNIZATION HISTORY & TUBERCULIN TEST Educational Attainment: _________________________________

    Disease/Age: ___________________________________________ Types/Age/Date given/Place/Untoward reactions: _____________ Source of Income: ______________________________________

    Severity: ______________________________________________ Exposure to Cigarette smoke: _____________________________

    Complications: _________________________________________ FAMILY HISTORY: Duration of exposure: ___________________________________

    Surgical Operation: ______________________________________ Father/Age: _______ Status: Alive:________, Deceased:________ Exposure to environmental pollutants: ______________________

    Condition: _____________________________________________ Fathers Condition: ______________________________________ Duration of exposure: ___________________________________

    Type: _________________________________________________ Mother/Age: _______Status: Alive: ________, Deceased: _______ Living arrangement (family/friends/relatives): ________________

    Place: ________________________________________________ Mothers Condition: _____________________________________ Physical and social aspect of home: _________________________

    Disease/Age: ___________________________________________ Siblings: #Brother: _______________ #Sister: ________________ # Storey: ____________________ # rooms: __________________

    Severity: ______________________________________________ Siblings/Age: ___________________________________________ # Occupants: _________________ # CR: _____________________

    Complications: _________________________________________ Siblings/Health status: ___________________________________ Window type: ________________ Ventilation: _______________

    Allergy/Eczema/Food or Drug Sensitivity/Other: ______________ Position in the family: ____________________________________ Location of residence: ___________________________________

    Disease/Age: ___________________________________________ Heredofamilial diseases: _________________________________ Interpersonal relationship: ________________________________

    Severity: ______________________________________________ HPN: _____________ Diabetes: ___________ Arthritis: ________ Sources of drinking water: ________________________________

    Complications: _________________________________________ PTB: _____________ CVD: _______________ Asthma: _________ Source of domestic water: ________________________________

    Asthma: ______________________________________________ Allergies: _________ Cancer: ____________ Psychiatric: _______ Sanitation (inside and outside): ____________________________

    Disease/Age: ___________________________________________ Hematologic: __________________ Seizures: ________________ Garbage disposal: _______________________________________

    Severity: ______________________________________________ Peptic ulcer: _________ BPH: ____________ Twinning: ________ Type of toilets disposal: __________________________________

    Complications: _________________________________________ Chromosomal/Congenital Abn: ____________________________ Pets: _________________________________________________

    Injury: ________________________________________________ Others: _______________________________________________ REVIEW OF SYSTEMS:

    1. GENERAL: ( ) fatigue, ( ) weight change, ( ) fever, (


    Effect: ________________________________________________ SOCIOECONOMIC & ENVIRONMENTAL HISTORY
    ) chills, ( ) delay in growth
    Signs & Symptoms: ______________________________________ Father/Age: ____________________________________________ 2. SKIN: ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( )
    hives, ( ) pigmentation, ( ) acne, ( ) Pruritus
    Course of Illness: _______________________________________ Occupation: ___________________________________________
    3. HEAD and NECK: ( ) headache, ( ) trauma, ( ) pain, ( ( ) number of pregnancies, ( ) number and types of
    ) stiffness, ( ) swelling deliveries, ( ) abortions, ( ) birth control method, (
    ) menopause (age)
    a. EYES: ( ) pain, ( ) diplopia, ( ) scotoma, (
    ) visual dysfunction , ( ) dryness, ( ) 11. MALE GENITALIA: ( ) pain, ( ) swelling, ( ) urethral
    redness, ( ) tearing, ( ) use of corrective discharge, ( ) hernias, ( ) testicular pain, ( )
    lenses masses, ( ) history of venereal diseases, ( ) erectile
    dysfunction/ potency, ( ) sexual habits, ( ) ulcers
    b. EARS: ( ) difficulty hearing/ deafness, ( )
    tinnitus, ( ) pain, ( ) discharges, ( ) 12. MUSCULOSKELETAL: ( ) muscle pains, ( ) joint pains,
    vertigo/dizziness ( ) cramps, ( ) weakness, ( ) stiffness, ( ) history of
    trauma, ( ) swelling, ( ) limitation of motion, ( )
    c. NOSE: ( ) epistaxis, ( ) dryness, ( )
    backache
    pain, ( ) discharges, ( ) obstruction, (
    ) smell dysfunction, ( ) sneezing 13. HEMATOLOGICAL: ( ) anemia, ( ) excessive bleeding,
    ( ) easy bruising, ( ) past transfusions, ( )pallor
    d. MOUTH: ( ) soreness, ( ) pain, ( )
    ulcers, ( ) hoarseness, ( ) dryness, 14. ENDOCRINE AND METABOLIC: ( ) heat/cold
    ( )gum and dental problems intolerance ( ) weight/ change, ( ) polydipsia, ( )
    polyphagia, ( ) polyuria, ( ) hair change
    4. BREASTS: ( ) discharges, ( ) lump/mass, ( )pain, (
    ) bleeding, ( ) infection 15. NERVOUS SYSTEM: ( ) headaches, ( ) syncope, (
    ) seizures, ( ) weakness, ( ) head trauma, ( )
    5. RESPIRATORY: ( ) cough, ( ) dyspnea/shortness of
    stroke, ( ) sleep disorder, ( ) coordination problem,
    breath, ( ) sputum, ( ) hemoptysis, ( ) cyanosis,
    ( ) sensory disturbance, ( ) motor problem, ( )
    ( ) wheezing/ asthma, ( ) occupational exposure, ( )
    tremors, ( ) memory
    tuberculosis/PTB exposure, ( ) past PPD, ( )
    previous chest x-ray 16. PSYCHIATRIC/ EMOTIONAL: ( ) anxiety, ( )
    depression, ( ) loss of control/ violence, ( )
    6. CARDIAC: ( ) chest pains/discomfort, ( )orthopnea,
    nervousness, ( ) memory change, ( ) suicide
    ( ) dyspnea, ( ) paroxysmal nocturnal dyspnea,
    attempts, ( ) substance abuse
    ( ) palpitations, ( ) undue fatigue, ( ) edema, ( )
    cyanosis, ( ) syncope, ( ) hypertension, ( ) past
    heart diseases, ( ) exercise limits

    7. VASCULAR: ( ) intermittent claudication, ( ) leg


    cramps, ( ) ulcers, ( ) varicose veins

    8. GASTROINTESTINAL: ( ) anorexia, ( )
    nausea/retching, ( ) vomiting, ( ) dysphagia, ( )
    hematemesis, ( )indigestion, ( ) melena, ( )
    hematochezia, ( )heartburn, ( ) abdominal pain, (
    ) hernia, ( ) hemorrhoids, ( ) use of laxatives

    9. RENAL AND INJURY: ( ) dysuria, ( ) hematuria, ( )


    incontinence, ( ) nocturia, ( ) urinary frequency, ( )
    dribbling, ( ) kidney stones

    10. GYNECOLOGICAL: ( ) menarche (age), ( ) cycle, ( )


    duration of menstruation, ( ) abdominal bleeding, (
    ) vaginal discharge, ( ) itchiness, ( )
    dysmenorrhea/ pelvic pain, ( ) dyspareunia, ( )
    contraceptive use, ( ) history of venereal diseases,

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