Pediatric Assessment tool Birth hx:

Informant: Prenatal: Natal:

(General physical
Patients name:
state of mother
Patients nickname: during pregnancy)
Sex: Date of Birth:
Age during the Birth Place:
Name of Parents: pregnancy (Hospital/clinic/Home)
Father: Age: Occupation: Wt gain Weight
Nausea (duration) Length
Mother: Age: Occupation Vomiting AOG
Address: Tel #: (duration)
Edema Birth order
Religion HTN Type of delivery
Primary Language Language understood: Albuminuria
UTI
Vaginal Bleeding Neonatal
C/C: Illness (including Apgar score
rashes, fever,
syphilis)
HPI: Start, list and describe current symptoms and work backward to onset. It should answer Indications: Respiratory problems
question related to where, what, when and how much of symptoms) Xray (month) Cyanosis
General emotional Congenital anomalies
state of mother
Medications Mothers blood tyoe
Was pregnancy Childs blood type
planned
Attitude of father Length of hospital stay
Prolonged NB screening
depression states
Frequent crying
spells
Previous abortions
or miscarriages

PMHx: (appetite, recent weight loss or gain, fatigue and stressors) Do not include information
that are already gathered under c/c or present illness.) Infancy and Childhood
Feeding hx
- Breastfed? (until when)
- Bottlefed? (until when)
Age of introduction of solid foods:
Food preferences
Vitamins (when introduced, duration)
Iron (when introduced, duration)
Fluoride (when introduced, duration)
Feeding problem (type)
- Vomiting
- Colic
- Regurgitation
1. Hospitalizations and childhood dses, surgeries, injuries and disabilities (Date and - Lethargy
complications) - Constipation
2. Previous health care contacts: past health exams. Last immunizations, lab tests. - Diarrhea
(Dates and results) - Allergic reaction

Growth and Development
1. Patients approximate ht_____ and wt______ at 1, 2, 5 and 10 yrs old
2. When first tooth erupted _____________________
3. When tooth loss occurred ____________________
4. Is patient obese _______ underwt_____________
5. Tall _______ Short ________ (for the age group)
6. Age when child was able to
roll over ______________________________
sit alone without support ________________
crawl ________________________________
walk _________________________________
speak first word and sentences ___________
dress without help _____________________
Behavior and social hx
1. Age when child began toilet training_____________________
2. Age when child achieve day and night level of control_______
3. Problem associated with it (pertaining to 1 and 2) __________
4. Terminology usedin toilet training _______________________
5. Amount and patterns of sleep: Day: ________ Night: _______
6. Any bedtime rituals___________________________________
7. Any security objects __________________________________
8. Level of awareness of sexuality _________________________
9. Any habits (lip biting, thumb sucking, pica, head banging and others)
___________________________________________________
10. Patients personality and temperament (any temper tantrums, shy or withdrawing,
childs relationship to other children and family)
___________________________________________________
___________________________________________________
___________________________________________________
Immunization
1. Details of immunizations
Booster
BCG
OPV
DPT
Measles
Hep B
MMR
Hib
Others
2. If child is not immunized: note reasons_____________________________________
3. Any screening tests related to immunization such as PPD______________________
Current Medications
Include any OTC drug prescription drugs, their dose, frequency and the time of the last dose.
Includes reasons for giving the meds and any side effects or intolerance or any allergies.
Family Hx
Info on health of family members. Any major health and genetic disorders (HPN, cancer, cardiac respiratory,
renal, cerebro vascular or thyroid disorders, asthma and other allergic manifestations, blood dyscrasias,
psychiatric difficulties, TB, DM, hepatitis, immunosuppression, etc). Info on concerns of parents and influence
of the health problem on the patients life as a family member. Info on cultural interpretation of anillness in
relation to the patient and any personal beliefs of the family that affects the illness. Family structure (includes
family composition, birth order and gender of the other children). Family envt (neighborhood, family member
with disability and community services available). Mechanics of eating, dressing, sleeping and patterns of daily
living in the family.
General review of systems
1. General: wt ___ recent wt change _____ temp _____ fatigue _____
2. Skin: rashes ____ lumps ____ sores ____ itching ____ dryness ____ color changes
____ changes in hair or nails ____
3. Eyes: blurring of vision ____ pain ____ redness ____ double vision ____ headache
____
4. Ears: hearing ____ tinnitus ____ vertigo _____ earaches ____ discharge ____
5. Nose and sinuses: frequent colds ____ nasal stuffiness ____ nasal discharge ____
itchiness ____ nosebleeds ____
6. Mouth and throat: Condition of teeth and gums ____ toothache ____ gum bleeding
____
7. Neck Lumps ____ pain ____ swollen glands ____ goiter ____
8. Breasts: Lumps ____ pain ____ or discomforts ____
9. Respiratory: chronic cough ____ wheezing ____ frequent colds ____
10. Cardiovascular: Cyanosis ____ limitation of activity ____ dyspnea on exertion ____
irritability _____
11. GIT: Abnormal appetite ____ diarrhea ____ abdominal pain ____ vomiting _____
Constipation _____
12. GUT: Enuresis _____ Painon urination ____ Hematuria ____ Polyuria ____ Nocturia
____ incontinence _____
13. Peripheral Vascular: murmurs ____ signs of CHF ____ bounding pulse ____
14. Musculo-skeletal: Muscle pains how often) _________________________________
abnormal gait ______
15. Neurologic: fainting ____, seizure ____, tremors _____
16. Hematologic: Anemia _____, easy bruising or bleeding ________
17. Endocrine: excessive sweating ____, excessive thirst or hunger ____
18. Psychiatric: Mood _________________________________________
Hints when performing Physical examination for children
1. It is best to perform assessment in areas that the child considers safe
2. Avoid the childs bed, bedroom and play area
3. Toys and other distractions should be with in easy reach to help facilitate assessment
4. Avoid nose
5. Make sure all equipments are in working order before starting the physical
examination
6. Anything considered threatening or strange should be kept out of sight of the child
7. Warm your hands and the equipment before placing on to the child
8. Observe areas of distress that needs immediate assessment
9. Height , head circumference, weight, DTR and neurologic tests need not always be
done
10. Work quickly and calmly, talking both to the child and the parent
11. Perform the least distressing aspects of the examination first
12. Use firm but kind approach
13. What is distressing to one age group may not be distressing to the other age group
14. It is best to tell the child what you are about to do rather to ask his permission
15. Never leave an infant or child unattended on an examination table
16. Auscultate the lungs, heart and abdomen at the beginning of the examination or
when the infant is not crying or extremely active
17. Take rectal temperature and perform other painful or intrusive examinations near the
end or at the end of examination