GENERAL DATA Birth:

Name: ____________________________________________________________ Delivered: _____ AOG via ( ) NSD/( ) CS by _____________ in _____________

Sex: ______ Age: _______ Weigh t: _________ kg Height: ________ cm Birth weight: _______ kg ( ) cord coil ( ) meconium stained amniotic fluid
Birthday: _________________________ Birth Place: _____________________ ( ) Vit K ( ) BCG ( ) NBS: Result: ______________________ ____________
 Address: _________________ ________________________ _________________ Complications: _____________________________ Sent home after: _____ days
Citizenship: ( ) Filipino ( ) Others: ____________________ ________________ IMMUNIZATION HISTORY
Religion: ( ) RC ( ) INC ( ) Born Again Others: _____________________ __ ( ) BCG ( ) Rotavirus
Date of Admission: ___________________ Time of Admission: ________ AM / PM ( ) DPT 1 ( ) DPT 2 ( ) DPT 3 ( ) PCV/PPV
Informant: _______________________________ Reliability: _________________ ( ) OPV 1 ( ) OPV 2 ( ) OPV 3 ( ) Influenza
( ) Hep B 1 ( ) Hep B 2 ( ) Hep B 3 ( ) Varicella
CHIEF COMPLAINT: 
COMPLAINT:  ________________________________________________ ( ) Measles ( ) MMR ( ) Hep A
HISTORY OF PRESENT ILLNESS ( ) HiB ( ) HPV
Please indicate the O nset,
nset, P rovocation/ 
rovocation/ P 
Palliation,
a  lliation, Q uality
uality of Pain, R egion
egion and R adiation,
adiation, S everity,
everity, Given in: ________________ Complications: ______________________________
T ime
ime (History),  Aggravating/  Alleviating Factors,  Associated Symptoms,  Attributions/  Adaptations NUTRITIONAL AND FEEDING HISTORY
( ) Breastfed Duration: _________________ Age Weaned: ________________
( ) Milk Formula: _________________ Dilution: ______ ______oz Q _____ hrs
Started complimentary feeding: _______ months
24-hour food recall:
Breakfast: _________________________________________________________
Merienda: _________________________________________________________
Lunch: ____________________________________________________________
Merienda: _________________________________________________________
Dinner: ___________________________________________________________
Food Preferences: 
Preferences:  __________________________________________________
GROWTH AND DEVELOPMENTAL HISTORY
MILESTONES NORMAL ACTUAL MILESTONES NORMAL ACTUAL
Regards 1 Drinks from cup 9 - 17
Smiles 2 Toilet-trained 14 - 48
Turns head 3 Feeds self 18 – 36
Holds head 4 Undresses 20 - 36
Rolls over 5 Vertical/circular strokes 2 yrs
Transfers object 6 Copies circle 3 yrs
Sits briefly 7 Writes name
Creeps 8 Says mama/dada 5 – 14
Pulls up 9 2-3 word sentences 2 yrs
Cruises 10 Knows name & gender 3 yrs
Stands alone 12 Asks questions 3 yrs
REVIEW OF SYSTEMS Walks alone 15 Counts
Constitutional: (–)
Constitutional:  (–) fever, (–) anorexia, (–) weight loss Runs 18 Says songs/tells stories 4 yrs
HEENT: (–) ear pain, (–) aural discharge, (–) epistaxis, (–) sore throat Up and down stairs 2 yrs Asks meanings of words 5 yrs
Cardiovascular: (–)
Cardiovascular:  (–) cyanosis, (–) palpitations, (–) orthopnea, (–) easy fatigability Schooling: ____________________ Performance: ( ) good:________ ( ) poor
Respiratory: (–)
Respiratory:  (–) dyspnea, (–) hemoptysis PAST MEDICAL HISTORY
Gastrointestinal: (–)
Gastrointestinal:  (–) vomiting, (–) diarrhea, (–) constipation ( ) Measles ( ) Chickenpox ( ) Mumps ( ) Asthma
Genitourinary: (–)
Genitourinary:  (–) discharge, (–) oliguria, (–) dysuria ( ) Previous Hospitalizations: ______________________ ____________________
Endocrine: (–)
Endocrine:  (–) heat/cold intolerance, (–) polyuria, (–) polydipsia, (–) polyphagia ( ) Surgical Procedures: ___________________________ When? ____________
Musculoskeletal: (–)
Musculoskeletal:  (–) joint pain, (–) muscle pain
 Allergies: ( ) Drug: ________________ __ ( ) Food: _________________ ___
Hematologic: (–)
Hematologic:  (–) pallor, (–) bleeding manifestations, (–) easy bruising
Neurologic: (–)
Neurologic:  (–) tremors, (–) increase in sleeping time Maintenance Medications: _____________________________________________
BIRTH AND MATERNAL HISTORY FAMILY HISTORY
Maternal: (indicate whether maternal or paternal side)

 Age of the mother: _______ OB Score: G P ( - - - ) Similar illness in the family: ___________________________________________
( ) PTB ( ) seizure
( ) smoker ( ) alcoholic beverage drinker ( ) illicit drug use: _______________
( ) bronchial asthma ( ) hypertension
Prenatal Check-up: total of ___________ PNCUs ( ) cancer ( ) diabetes mellitus
Start: _____________________ AOG Attended by: _________________________ ( ) heart disease ( ) kidney diseases
Last: ______________________ AOG Attended by: ________________________ Others: ____________________________________________________________
Prenatal Medications: ________________________________________________ SOCIAL AND ENVIRONMENTAL HISTORY
UTZ: _________ AOG: ______________ _________ AOG: ______________ House: ________ storey ( ) concrete ( ) wooden
Maternal Illnesses During Pregnancy: ____________________________________ Ventilation: ________________ Lighting: __________________
Labs done/Meds taken: _______________________________________________ No. of household members: _________
Date Sex AOG Manner Place Attendant Complications Drinking water: _______________________ ____ If tap, boiled? ( ) Yes ( ) No
G1 Garbage Disposal: _______________ _____ x/week Toilet: ________________
G2 ( ) History of travel: _______________________ _____ When? ______________
G3 ( ) Exposure to smoking ( ) Nearby Dumpsite ( ) Nearby factories
G4 ( ) Pets: _____________________ ____ Stay inside the house? ( ) Yes ( ) No
G5  !" $%&'() *+ $' ,- . /012
 PSYCHOSOCIAL ASSESSMENT FOR ADOLESCENTS (HEADSSFIRST)
HOME. Space, privacy, frequent geographic moves, neighborhood.

EDUCATION/SCHOOL. Frequent school changes, repetition of a grade/ in each

subject, teachers’ reports, vocational goals, after-school educational clubs
(language, speech, math, etc.), learning disabilities

ABUSE. Physical, sexual, emotional, verbal abuse; parental discipline

DRUGS. Tobacco, alcohol, marijuana, inhalants, “club drugs,” “rave” parties, others.

Drug of choice, age at initiation, frequency, mode of intake, rituals, alone or with
peers, quit methods, and number of attempts

SAFETY. Seat belts, helmets, sports safety measures, hazardous activities, driving

while intoxicated

SEXUALITY/SEXUAL IDENTITY. Reproductive health (use of contraceptives,

presence of sexually transmitted infections, feelings, pregnancy)

FAMILY AND FRIENDS. Family: Family constellation, genogram, single/

married/separated/divorced/blended family, family occupations and shifts; history of
addiction in 1st- and 2nd-degree relatives, parental attitude toward alcohol and
drugs, parental rules; chronically ill physically or mentally challenged parent.
Friends: peer cliques and configuration (“preppies,” “jocks,” “nerds,” “computer
geeks,” cheerleaders), gang or cult affiliation

IMAGE. Height and weight perceptions, body musculature and physique,

appearance (including dress, jewelry, tattoos, body piercing as fashion trends or
other statement)

RECREATION. Sleep, exercise, organized or unstructured sports, recreational

activities (television, video games, computer games, Internet and chat rooms, church
or community youth group activities [e.g., Boy/Girl Scouts; Big Brother/Sister groups,
campus groups]). How many hours per day, days per week involved?

SPIRITUALITY AND CONNECTEDNESS. Use HOPE* or FICA † acronym;

adherence, rituals, occult practices, community service or involvement
HOPE, hope or security for the future; organized religion; personal spirituality and practices;
effects on medical care and end of life issues.
† 
FICA, faith beliefs; importance and influence of faith; community support.

THREATS AND VIOLENCE. Self-harm or harm to others, running away, cruelty to

animals, guns, fights, arrests, stealing, fire setting, fights in school

 !" $%&'() *+ $',- . /012