Name of informant:___________________________

Relationship to patient:_______________________ NATAL HISTORY:

% Reliability: __________________________________ __preterm ___term ___postterm

GENERAL DATA: Manner of delivery:_______ Presentation: ______

Duration of labor:________________________________
Name:____________________________________________ Did the baby breathe spontaneously? _________
Age: ____________ Gender:_________________________ APGAR score: _____________
Date of Birth: ____________________________________ Cord coil: Y/N
Place of Birth: ___________________________________ Meconium aspiration: Y/N
Nationality:______________________________________ Placental and cord appearance:________________
Religion: _________________________________________ ____________________________________________________
Address: __________________________________________
____________________________________________________
____________________________________________________ NEONATAL HISTORY:
No. of times admitted: _________________________ Duration of stay in nursery:____________________
Date of admission: ______________________________ Infections: Y/N Convulsion: Y/N
Place of Admission:_____________________________ Jaundice: Y/N Transfusion: Y/N
Bililite used: Y/N
CHIEF COMPLAINT:_____________________________ Bleeding problems: Y/N
____________________________________________________ Breathing problems: Y/N

HISTORY OF PRESENT ILLNESS: NUTRITIONAL RECORD:

____________________________________________________ Breast fed (age): ______________
____________________________________________________ Bottle fed (age): _________ Formula:_____________
____________________________________________________ Mixed fed (age): _________
____________________________________________________ How good an eater was the baby? _____________
____________________________________________________ Weaning introduced (age): _____________________
____________________________________________________ Food used in weaning: __________________________
____________________________________________________ Sequence of weaning: ___________________________
____________________________________________________ Weight gain pattern: ____________________________
____________________________________________________
____________________________________________________ PAST MEDICAL HISTORY:
____________________________________________________
____________________________________________________ Prior Illness: Y/N
____________________________________________________ if yes: _____________________________________________
____________________________________________________ Hospitalizations: Y/N
____________________________________________________ if yes: _____________________________________________
____________________________________________________ Infections: Y/N
____________________________________________________ if yes: _____________________________________________
Surgery: Y/N
if yes: _____________________________________________
PRENATAL HISTORY: Accidents: Y/N
if yes: _____________________________________________
G____ P___ (T___ P___ A___ L____) Frequency of cough and colds: ______/year
Age of Mother (at the time of birth): ___________
Any illnesses during pregnancy? IMMUNIZATIONS:
____________________________________________________ __BCG __Pneumococcal
____________________________________________________ __Hepa B __MMR
Medications: ____________________________________ __DPT __Measles
____________________________________________________ __OPV __Varicella
Exposure to radiation/chemicals: _____________ __Hib __Tetanus ___Rabies
DEVELOPMENTAL MILESTONES: School History:
__raise head __________________________________________________
__spontaneous smile
__turned when called
__head control FAMILY HISTORY
__pick up objects
__social smile Relatives- Age- Health Status
__crawl Mother: ___________________________________________
__pulls to stand Father:____________________________________________
__sat up unsupported Babysitter:________________________________________
__sits w/o support Siblings:___________________________________________
__walk w/o support ____________________________________________________
__can hold ball ____________________________________________________
__says “mama” and “papa” _Others:___________________________________________
__ plays with simple ball game
__2 words beside “mama” and “papa”
__knows name and age SYSTEM REVIEW:
__walk upstairs with one foot after another
__run and skip General
__scribbles, draw circles __ Weight loss __Activity level __ Fever
__speak in phrases __Appetite __Weight gain __ Growth delay
__walks upstairs with alternating feet __ Delayed developmental milestones
__draw a man’s head, face and body
__speak in complete sentences Skin
__ can hold spoon and fork ___ Rash ___Birth Mark ___ Pigmentation
___Hair Loss

SOCIAL AND PERSONAL HISTORY Head and Neck

Feeding ___ Headache ___head injuries
Eating pattern:____________________________
Likes and dislikes:________________________ Ears
Sleeping ___ Past infections ___ Hearing loss
No. of hours: _____________________________ ___Drainage
Bed wetting ( if applicable)_____________
Toileting Eyes
Bowel control: yes/no ___ Past infections ___Visual prob ___Squint
Bladder control: yes/no
Games and play: __________________________ Nose
Living arrangement: ___ Past infections ___Bleeding ___Nasal block
Nuclear/single parent/ extended ___ Mouth breathing

Current household members – Health status Mouth, Teeth and throat

____________________________________________________ ___Ulcers ___Dental Caries ___Thumb sucking
____________________________________________________ ___ Sore throat ___Hoarse voice
____________________________________________________
____________________________________________________ Neck:
____________________________________________________ ___Stiffness ___Pain

Sources of support: Respiratory:

___________________________________________________ __Cough __Wheeze __Dyspnea __Chest pain
CVS:
__Cyanosis __Pallor __ Squatting
__ Tolerance for physical activity

GIT:
__Vomiting ___Abd pain __Diarrhea
__Constipation __Jaundice __Parasitic infection

Urinary Tract:
__Frequency __Discharge __Enuresis
__Edema of hands and feet

Genital
__Discharge __Itching
__Menstrual period __Swelling testes

Endocrine
__Neck mass __Cold intolerance __loss of hair
__Acne _Breast Devt: ___________________________
Assymetry ___________ Discharge______________

CNS
__ Seizure __Ataxia __Paresthesia
__Mental deterioration ___School failure
__Speech prob __Weakness

Blood
__Easy Bruising __unusual bleeding
__Large nodes __Bone pain

Musculo
__Limping __Limitation of Motion

Immunologic
__Recurrent infection

Psychologic
__Memory Loss __Sleep prob __Eating prob
__School failure __Hallucination
__Mood changes __Encopresis