Patient’s Name

Last Name First Name Middle Name Case#

Place of
Residence
Single Married _ Separated
Birthday/ Age Civil Status
Nationality
Place of Birth
& Ethnicity
Gender Male _ Female
Religion
For the Guardian
Name Occupation

April 21, 2022

Reliability (%) Date and Time of interview

Chief
Complaint

Symptom 1 Symptom 2 Symptom 3

Onset

Location/ radiation

Duration

Character

Aggravating factors

Relieving factors

Timing

Severity

Radiation

Associated symptoms

HISTORY OF PRESENT ILLNESS

 REVIEW OF SYSTEMS
A. General
Weight changes
(clothes that fit more loosely
or tightly than before)
Weakness/ Fatigue/
Fever

B. Skin

C. Head/ Eyes/ Ears/ Nose/ Throat

( )Headache ( )Head injury ( )dizziness ( )lightheadedness
Head

( )Glasses & Contact Lenses ( )Pain/ Redness ( )Excessive tearing ( )double vision
Eyes ( )blurring or flashing lights ( )Last eye check-up?

( ) Ringing Tinnitus ( )Vertigo Earache or Discharge/

Ears

( )Frequent colds ( )Nasal stuffiness ( )Discharge ( )Bleeding ( )Sinus trouble

Nose & Sinuses ( ) Changes in sense of Smell

( )Teeth ( )Gums & Bleeding ( )Sore Tongue ( )Dry mouth ( )Frequent sore throats (
Throat (or Mouth and ) hoarseness ( )Taste and Swallowing Difficult Last Dental Check-up?___________
Pharynx)

( )Lumps (swollen glands) ( )Goiter ( )Pain or Stiffness

D.Neck

( )Lumps ( )Pain or Discomfort ( )Nipple Discharge

E.Breast

( )Cough/Sputum(Color/Quantity) ( ) Hemoptysis (Blood ( )/Dyspnea

F. Respiratory (Difficulty of breathing) ( ) Wheezing (sound in breathing) ( )Pleurisy (Burning
sensation in the chest) History of: ( )Asthma( )TB( )Pneumonia
( )Chest Pain ( )Palpitations ( )Rheumatic Heart Murmurs
G. Cardiovascular ( ) Edema

( )Dysphagia (trouble swallowing) ( )Appetite and Changes ( )Nausea

H.Gastrointestinal Color & size of Stool ( ) Changes in bowel habits /
( )Constipation ( ) Diarrhea ( )Pain ( )Food Intolerance ( )Excessive Belching or Passing
of Gas( )Jaundice ( )Hepatitis ( )Gallbladder problem
( )Dysuria ( ) History of UTI ( ) Hematuria
I. Urinary

Male: ( )Pain ( ) mass

J. Genital Female: ( )Menarche ( )Regularity ( )Frequency & Duration ( ) Discharge ( )Sores
( )Lumps

Muscle or joint pains / Stiffness / Arthritis / Gout / Backache/ Location /

L. Musculoskeletal Swelling/ Redness/ Pain/ Tenderness/Weakness or Limitation/ Timing, Durationand
History ofTrauma

( )Fainting ( ) Blackouts or Loss of Vision ( ) Diplopia (double vision) ( )Difficulty hearing

M. Neurologic or Tinnitus ( )Dysphagia ( )Seizures ( )Weakness ( )Tremors
( )Gait, Balance or CoordinationProblems( ) Memory or Cognitive ( )Sleep Problems ( )Mood
Swings ( )Depression

( )Anemia ( )easy bruising or bleeding ( )Past Transfusion and/or Reactions

N.Hematologic

O. Endocrine ( )Thyroid trouble ( ) Heat or Cold intolerance ( )Excessive sweating ( )Excessive Thirst
or Hunger ( )Polyuria
 ( )Nervousness( ) Tension( )Mood ( ) Depression( ) Memory Changes ( )Suicide Attempts if
P.Psychiatric relevant

PAST PERSONAL HISTORY

A. GESTATIONAL

Mother’s age during pregnancy:

OB score: G_P_ (____)

Pre-natal check-up: regular, irregular (when)

Infections
Onset:
Duration:
Severity:
Medications: Multivitamins, Folic, Iron

Screening Tests: Hepa B, HIV

Planned or Unwanted Pregnancy

Use of Illcit Drugs/Abortifacient

Age during Hospital/Atte Form of Birthweight

Year of Birth AOG Complications
pregnancy ndant Delivery (Kg)

B. BIRTH HISTORY

( )Term, ( ) premature, ( ) post mature

Manner of delivery: CS, NSD

Person who attended the delivery

Birth weight:

C. NEONATAL

Spontaneous respiration or required

resuscitation

APGAR score

Complications:
- jaundice, convulsions, difficulty
breathing
- poor feeding
- medications given
- extended hospital stay/NICU stay d/t
- Congenital abnormalities
- Birth injury
 D. FEEDING NUTRITIONAL

Infancy:
• Breastfed:
Frequency per day
Duration each breast
• Mixed/Milk fomula:
• Reason for not BF:
• Formula:
Amount given per day:
Bottle or cup fed:
(<2y/o)
Complement Age Frequenc
ary food: introduced: y per day:

Childhood and Adolescents: (2-20 yo)

Appetite prior to onset of illness
Picky-eater even when she was not sick:
Include sample diet/day:

Breakfast juice, biscuit

Lunch may sabaw, tinola, sinigang

Maling, tocino

Dinner same

Snacks juice, brownies, biscuits

E. DEVELOPMENTAL (1-5 years old)

Child Development Assessment
CDC MILESTONES
2 MONTHS Social and Emotional ( )Begins to smile at people
( )Can briefly calm himself (may bring hands to mouth and suck on
hand)
( )Tries to look at parent
Language/Communication ( )Coos, makes gurgling sounds
( ) Turns head toward sounds
( ) Baby raising head and chest when lying on stomach
Cognitive (learning, ( ) Pays attention to faces
thinking, problem-solving) ( ) Begins to follow things with eyes and recognize people at a
distance
( ) Begins to act bored (cries, fussy) if activity doesn’t change
Movement/Physical ( ) Can hold head up and begins to push up when lying on tummy
Development ( ) Makes smoother movements with arms and legs

4 MONTHS Social and Emotional ( ) Smiles spontaneously, especially at people

( ) Likes to play with people and might cry when playing stops
( ) Copies some movements and facial expressions, like smiling or
frowning
Language/Communication ( ) Begins to babble
( ) Babbles with expression and copies sounds he hears
( ) Cries in different ways to show hunger, pain, or being tired baby on
floor with toy
Cognitive (learning, ( ) Lets you know if she is happy or sad
thinking, problem-solving) ( ) Responds to affection
( ) Reaches for toy with one hand
( ) Uses hands and eyes together, such as seeing a toy and reaching
for it
( ) Follows moving things with eyes from side to side
( ) Watches faces closely
( ) Recognizes familiar people and things at a distance
Movement/Physical ( ) Holds head steady, unsupported
Development ( ) Pushes down on legs when feet are on a hard surface
( ) May be able to roll over from tummy to back
( ) Can hold a toy and shake it and swing at dangling toys
 ( ) Brings hands to mouth
( ) When lying on stomach, pushes up to elbows
6 MONTHS Social and Emotional ( ) Knows familiar faces and begins to know if someone is a stranger
( ) Likes to play with others, especially parents
( ) Responds to other people’s emotions and often seems happy
( ) Likes to look at self in a mirror

Language/Communication ( ) Responds to sounds by making sounds

( ) Strings vowels together when babbling (“ah,” “eh,” “oh”) and likes
taking turns with parent while making sounds
( ) Responds to own name
( ) Makes sounds to show joy and displeasure
( ) Begins to say consonant sounds (jabbering with “m,” “b”) mother
enjoying 7 month old infant

Cognitive (learning, ( ) Looks around at things nearby

thinking, problem-solving) ( ) Brings things to mouth
( ) Shows curiosity about things and tries to get things that are out of
reach
( ) Begins to pass things from one hand to the other

Movement/Physical ( ) Rolls over in both directions (front to back, back to front)

Development ( ) Begins to sit without support
( ) When standing, supports weight on legs and might bounce
( ) Rocks back and forth, sometimes crawling backward before moving
forward
9 MONTHS Social and Emotional ( ) May be afraid of strangers
( ) May be clingy with familiar adults
( ) Has favorite toys
Language/Communication ( ) Understands “no”
( ) Makes a lot of different sounds like “mamamama” and
“bababababa”
( ) Copies sounds and gestures of others
( ) Uses fingers to point at things
( ) Doctor holding little boy
Cognitive (learning, ( ) Watches the path of something as it falls
thinking, problem-solving) ( ) Looks for things he sees you hide
( ) Plays peek-a-boo
( ) Puts things in her mouth
( ) Moves things smoothly from one hand to the other
( ) Picks up things like cereal o’s between thumb and index finger
Movement/Physical ( ) Stands, holding on
Development ( ) Can get into sitting position
( ) Sits without support
( ) Pulls to stand
( ) Crawls
1 YEAR Social and Emotional ( ) Is shy or nervous with strangers
( ) Cries when mom or dad leaves
( ) Has favorite things and people
( ) Shows fear in some situations
( ) Hands you a book when he wants to hear a story
( ) Repeats sounds or actions to get attention
( ) Puts out arm or leg to help with dressing
( ) Plays games such as “peek-a-boo” and “pat-a-cake”
Language/Communication ( ) Responds to simple spoken requests
( ) Uses simple gestures, like shaking head “no” or waving “bye-bye”
( ) Makes sounds with changes in tone (sounds more like speech)
( ) Says “mama” and “dada” and exclamations like “uh-oh!”
( ) Tries to say words you say
( ) Toddler sitting with mom playing xylophone
Cognitive (learning, ( ) Explores things in different ways, like shaking, banging, throwing
thinking, problem-solving) ( ) Finds hidden things easily
( ) Looks at the right picture or thing when it’s named
Copies gestures
( ) Starts to use things correctly; for example, drinks from a cup,
brushes hair
( ) Bangs two things together
( ) Puts things in a container, takes things out of a container
( ) Lets things go without help
( ) Pokes with index (pointer) finger
( ) Follows simple directions like “pick up the toy”
 Movement/Physical ( ) Gets to a sitting position without help
Development ( ) Pulls up to stand, walks holding on to furniture (“cruising”)
( ) May take a few steps without holding on
( ) May stand alone
18 MONTHS Social and Emotional ( ) Likes to hand things to others as play
( ) May have temper tantrums
( ) May be afraid of strangers
( ) Shows affection to familiar people
( ) Plays simple pretend, such as feeding a doll
( ) May cling to caregivers in new situations
( ) Points to show others something interesting
( ) Explores alone but with parent close by
( ) Toddler eating you from a blue bowl
Language/Communication ( ) Says several single words
( ) Says and shakes head “no”
( ) Points to show someone what he wants
Cognitive (learning, ( ) Knows what ordinary things are for; for example, telephone, brush,
thinking, problem-solving) spoon
( ) Points to get the attention of others
( ) Shows interest in a doll or stuffed animal by pretending to feed
( ) Points to one body part
( ) Scribbles on his own
( ) Can follow 1-step verbal commands without any gestures; for
example, sits when you say “sit down”
Movement/Physical ( ) Walks alone
Development ( ) May walk up steps and run
( ) Pulls toys while walking
( ) Can help undress herself
( ) Drinks from a cup
( ) Eats with a spoon
2 YEARS Social and Emotional ( ) Copies others, especially adults and older children
( ) Gets excited when with other children
( ) Shows more and more independence
( ) Shows defiant behavior (doing what he has been told not to)
( ) Plays mainly beside other children, but is beginning to include other
children, such as in chase games

Language/Communication
( ) Points to things or pictures when they are named
( ) Knows names of familiar people and body parts
( ) Says sentences with 2 to 4 words
( ) Follows simple instructions
( ) Repeats words overheard in conversation
( ) Points to things in a book
( ) 2 year old playing with big ball

Cognitive (learning, ( ) Finds things even when hidden under two or three covers
thinking, problem-solving) ( ) Begins to sort shapes and colors
( ) Completes sentences and rhymes in familiar books
( ) Plays simple make-believe games
( ) Builds towers of 4 or more blocks
( ) Might use one hand more than the other
( ) Follows two-step instructions such as “Pick up your shoes and put
them in the closet.”
( ) Names items in a picture book such as a cat, bird, or dog
Movement/Physical ( ) Stands on tiptoe
Development ( ) Kicks a ball
( ) Begins to run
( ) Climbs onto and down from furniture without help
( ) Walks up and down stairs holding on
( ) Throws ball overhand
( ) Makes or copies straight lines and circles
3 YEARS Social and Emotional ( ) Copies adults and friends
( ) Shows affection for friends without prompting
( ) Takes turns in games
( ) Shows concern for crying friend
( ) Understands the idea of “mine” and “his” or “hers”
( ) Shows a wide range of emotions
( ) Separates easily from mom and dad
( ) May get upset with major changes in routine
( ) Dresses and undresses self
 ( ) Toddler hugging doll
Language/Communication ( ) Follows instructions with 2 or 3 steps
( ) Can name most familiar things
( ) Understands words like “in,” “on,” and “under”
( ) Says first name, age, and sex
( ) Names a friend
( ) Says words like “I,” “me,” “we,” and “you” and some plurals ( )
(cars, dogs, cats)
( ) Talks well enough for strangers to understand most of the time
( ) Carries on a conversation using 2 to 3 sentences
Cognitive (learning, ( ) Can work toys with buttons, levers, and moving parts
thinking, problem-solving) ( ) Plays make-believe with dolls, animals, and people
( ) Does puzzles with 3 or 4 pieces
( ) Understands what “two” means
( ) Copies a circle with pencil or crayon
( ) Turns book pages one at a time
( ) Builds towers of more than 6 blocks
( ) Screws and unscrews jar lids or turns door handle
Movement/Physical ( ) Climbs well
Development ( ) Runs easily
( ) Pedals a tricycle (3-wheel bike)
( ) Walks up and down stairs, one foot on each step
4 YEARS Social and Emotional ( ) Enjoys doing new things
( ) Plays “Mom” and “Dad”
( ) Is more and more creative with make-believe play
( ) Would rather play with other children than by himself
( ) Cooperates with other children
( ) Often can’t tell what’s real and what’s make-believe
( ) Talks about what she likes and what she is interested in
Language/Communication ( ) Knows some basic rules of grammar, such as correctly using “he”
and “she”
( ) Sings a song or says a poem from memory such as the “Itsy ( )
Bitsy Spider” or the “Wheels on the Bus”
( ) Tells stories
( ) Can say first and last name
( ) Child throwing ball
Cognitive (learning, ( ) Names some colors and some numbers
thinking, problem-solving) ( ) Understands the idea of counting
( ) Starts to understand time
( ) Remembers parts of a story
( ) Understands the idea of “same” and “different”
( ) Draws a person with 2 to 4 body parts
( ) Uses scissors
( ) Starts to copy some capital letters
( ) Plays board or card games
( ) Tells you what he thinks is going to happen next in a book
Movement/Physical ( ) Hops and stands on one foot up to 2 seconds
Development ( ) Catches a bounced ball most of the time
( ) Pours, cuts with supervision, and mashes own food
5 YEARS Social and Emotional ( ) Wants to please friends
( ) Wants to be like friends
( ) More likely to agree with rules
( ) Likes to sing, dance, and act
( ) Shows concern and sympathy for others
( ) Is aware of gender
( ) Can tell what’s real and what’s make-believe
( ) Shows more independence (for example, may visit a next-door
neighbor by himself [adult supervision is still needed])
( ) Is sometimes demanding and sometimes very cooperative
( ) 5 year old playing guitar
Language/Communication ( ) Speaks very clearly
( ) Tells a simple story using full sentences
( ) Uses future tense; for example, “Grandma will be here.”
( ) Says name and address
Cognitive (learning, ( ) Counts 10 or more things
thinking, problem-solving) ( ) Can draw a person with at least 6 body parts
( ) Can print some letters or numbers
( ) Copies a triangle and other geometric shapes
( ) Knows about things used every day, like money and food

Movement/Physical ( ) Stands on one foot for 10 seconds or longer

 Development ( ) Hops; may be able to skip
( ) Can do a somersault
( ) Uses a fork and spoon and sometimes a table knife
( ) Can use the toilet on her own
( ) Swings and climbs

SCHOOL PERFORMANCE
(6-9 years old)

Grade/Year Level: grade 1

Fave subject: math
Least fave: writing
Grades: oks lang nakakasabay naman, madali
matuto

TANNER STAGE

PAST ILLNESSES Contagious diseases (age and courses)

( ) measles/Tigdas ______________________________________________________
( ) varicella/bulutong ______________________________________________________
( ) mumps/beke _______________________________________________________
( ) pertussis ______________________________________________________
( ) other __________________________________________________
● Hospitalization
Date __________________
Duration _________________
Medications given __________________________________________
( ) Operation ______________________________________________
( ) Injuries/Trauma/ Accident ________________________________________________
( ) Allergies _______________________________________________
( ) Eczema ________________________________________________
( ) Asthma ________________________________________________

IMMUNIZATION
AT BIRTH 6 WEEKS 10 WEEKS 14 WEEKS 9 MONTHS 1 YEAR
[ /] BCG [ ]Pentavalent Vaccine [ ]Pentavalent Vaccine [ ]Pentavalent Vaccine [ ] Measles, [ ]
(DPT, Hepatitis B, HiB) (DPT, Hepatitis B, HiB) (DPT, Hepatitis B, HiB) Mumps, Rubella Measles,
[/] [ ]Oral Polio Vaccine [ ]Oral Polio Vaccine [ ]Oral Polio Vaccine (MMR) Mumps,
Hepatitis B (OPV) (OPV) (OPV) Rubella
[ ]Pneumococcal [ ]Pneumococcal [ ]Pneumococcal (MMR)
Conjugate Vaccine Conjugate Vaccine (PCV) Conjugate Vaccine (PCV)
(PCV)
[ ] Inactivated Polio
Vaccine (IPV)

[ ] Other vaccines: ____________________________________________________________________

Based on DOH’s Expanded Program on Immunization

CURRENT HEALTH STATUS

A. Screening Test or
Laboratory Exams
B. Previous Surgery/
Hospitalizations
C. Medications/
Maintenance

FAMILY MEDICAL HISTORY

Father Age: ______
State of physical and mental health:
( ) Alive ( ) Deceased (cause of death): ____________________________
( ) Hypertension ( ) TB ( ) DM, ( ) syphilis, ( ) cancer ______________,
( ) epilepsy, ( ) rheumatic fever, ( ) allergy, ( ) anemia, ( ) thyroid disease,
 ( ) kidney disease, ( ) liver disease, ( ) stroke, ( ) asthma, ( ) mental retardation,
( ) congenital defects _____________, ( ) alcohol addiction, ( ) drug addiction
( ) suicide, ( ) hypercholesterolemia, ( ) smoking
Mother Age: ______
State of physical and mental health:
( ) Alive ( ) Deceased (cause of death): ____________________________
( ) Hypertension ( ) TB ( ) DM, ( ) syphilis, ( ) cancer ______________,
( ) epilepsy, ( ) rheumatic fever, ( ) allergy, ( ) anemia, ( ) thyroid disease,
( ) kidney disease, ( ) liver disease, ( ) stroke, ( ) asthma, ( ) mental retardation,
( ) congenital defects _____________, ( ) alcohol addiction, ( ) drug addiction
( ) suicide, ( ) hypercholesterolemia, ( ) smoking

Siblings Age State of Health

PERSONAL & SOCIAL HISTORY

Primary Caregiver

Living Circumstances Place:

Owned/Rent/ store:
Nature of dwelling:
Type of comfort room own cr:
Number of household members:
Ventilation:
Water sources Igib/gripo:
waste disposal:
sewage disposal
living near ( ) busy street, ( ) from accidental poisoning, ( ) factories, ( ) farm ( ) canals
Exposure to ( ) mosquitoes, ( ) dogs, ( ) cats, ( ) rats, ( ) chicken, ( ) flood ( /) smoke
Working members of the family:
Economic circumstances
Father’s Occupation:
Mother’s Occupation:
Sources of Fund:
Leisure Activities
Exercise & Diet
(Frequency, Usual
dailyfood
intake[caffeinated]
& Supplements)
Safety Measures observed
(seatbelts, sunblocks,
helmets)
Sexual Behavior &
Orientation

Duration per session

Exercise Type Frequency per week Regularity (Yes/No)
(Minutes/ Hours)

Amount consumed
Alcohol Intake Frequency per week Regularity (Yes/No)
(Minutes/ Hours)

𝑃𝑎𝑐𝑘 𝑌𝑒𝑎𝑟𝑠
Number of sticks per
Cigarette/ Tobacco use Length of years smoking # 𝑜𝑓 𝑠𝑡𝑖𝑐𝑘𝑠/ 𝑑𝑎𝑦
day = 𝑥 𝑌𝑒𝑎𝑟𝑠
20

Sleeping Pattern Number of hours per Difficulty Others

 day

HEADSS INTERVIEW INSTRUMENT

HOME Living with: _________________________ Own room: [ ] Yes [ ] No

Describe home relationships: ____________________________________________
Family moves often? [ ] Yes. How many? ____ [ ] No
Primary confidant: (to whom do you turn to when angry?) _____________________
What happens if parents are angry? _______________________________________
EDUCATION/ What grade is the teen in?
EMPLOYMENT School grades?
Favorite subjects? Best subjects? Worst?
Any failures? Repeated classes?
Truancy? Does the teen feel safe at school (bullying)?
Who does the teen turn to when he has problems?
Future goals or ambitions?
ACTIVITIES What does the teen do for fun?
Who are the teen’s peers?
Any organized sports? Clubs?
Any hobbies? Church attendance?
What does the teen do with peers?
With family? Does teen have a car?
Does teen use seatbelts?
DRUGS Used by peers? Used by teen?
Alcohol? Cigarettes? Marijuana?
How much? When? Where? With whom?
Use by family members?
Source? How is it paid for?
SEXUALITY Orientation? Sexual experience?
Number of partners? Masturbation?
History of pregnancy or abortion?
History of STIs? Contraception? Type?
History of physical or sexual abuse?
Suicide/ Sleep disorders? Fatigue? Appetite changes?
Depression Feeling of hopelessness? Isolation?
Boredom? Withdrawn? History of past suicide attempts?
History of family suicides?
History of recurrent accidents?
Decreased affect?
Preoccupation with death? Suicidal ideation?
Safety Do you often wear seatbelts?
Use helmet?
Used to go home late at night?
Involve to any street fights?

PHYSICAL EXAMINATION
I. General Survey
A. General Appearance

B. Level of Comfort/ Distress

C. Level of Consciousness

D. Skin Color

E. Ambulatory Status

F. Posture and General Motor

Activity
G. Body Habitus

H. Body symmetry

I. Personal Hygiene & Grooming

J. Facies
 K. Mood and Affect
- Attitude towards examiner
- Predominant Mood
- Affect
- Appropriateness
L. Psychomotor Activity & Speech
- Manner of Speech
- Abnormal movements
M. Thought process & Content

N. Cognitive Functions
- Orientation
- Memory
O. Nutritional Status

II. Skin, Hair, and Nails

A. Skin Discoloration

B. Lesions
- Primary
- Secondary
C. Vascular Lesions

D. Skin Turgor, Moisture,

Texture and Mobility
E. Hair Distribution &
Resiliency
F. Nails

III. Anthropometrics
A. Height

B. Weight

C. Body Frame estimate

D. Body Mass Index 𝑊𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝐾𝑔

BMI = 2
√𝐻𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑀

E. Midarm Circumference
(MAC)
F. Triceps Skin Fold (TSF)
Determination
G. Midarm Muscle MaMC =(𝑀𝐴𝐶[𝑐𝑚] − (0.314[𝑚𝑚]))
Circumference
H. Waist Circumference, Hip Waist-to-Hip Ratio (WHR) = 𝑊𝑎𝑖𝑠𝑡 𝑐𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒
𝐻𝑖𝑝 𝐶𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒
Circumference,
I. Loss of Subcutaneous Subcutaneous fats: Triceps, Midaxillary at costal margin, Interosseous and palmar,
Fats & Muscle Wasting Deltoids
Muscle wasting: Quadriceps femoris, Deltoid

IV. Vital Signs

Temperature Pulse Rate Respiratory Rate Blood Pressure Pain O2 sat

V. Head, Eyes, Ears, Nose, Throat (HEENT)

A. Head Head circumference

Lesion/Mass

Palpable occipital lymph node

B. Eyes Conjunctival redness

 Purulent discharge

Pupils (reactive to light, bilateral)

C. Ears Swelling and Tendernes

Post aurical lymphnodes

Otoscopy (no ear discharge, intact tympanic membrane, bilateral)

D. Nose Alar flaring

Nasal discharge

Nasal crease

oral mucosa

Mouth

E. Throat Oral ulcers

Tonsillar enlargement and pus

F. Neck Mass and tenderness

Palpable cervical lymph nodes

G. Skin Characteristic of rash and lesion

VI. Respiratory system

Inspection Alar flaring

cyanosis

Chest wall deformity None

Chest retractions

Palpation Chest lag

Tactile fremitus

Crepitus

Percussion

Ausculation Chest sound La naman sipol

VII. Cardiovascular
Inspection Precordium

Precordial bulge

Chest wall deformity

Palpation Point of maximal implulse

Apex beat

Thrills, heaves and lifts None

Capillary refill time

Auscultation Murmur

VIII. AbdomenIX. Abdomen

 Inspection Abdominal distention

Scars/ Masses/Bulges/Pus/Erythema on umbilicus

Ausculation Bowel sounds

Palpation Soft or tense

Mass

Liver edge (1 cm below costal margin) and span

Spleen

Percussion Fluid wave

Shifting dullness

X. Genitourinary
Male Penis : foreskin retracted or not

Abnormalities: ashypospadia or epispaadias.

Scrotum and testes: Descended or not

Inguinal Hernia

Female Labia majora and minora: ( ) inflammation ( ) inappropriate structures

Hymenal membrane:opening ( )imperforated hymen, sleeve or partitioned hymen)

Liver edge (1 cm below costal margin) and span

Spleen

Rectal Imperforated anus ( )

XI. Musculoskeletal
Hands clenched due to palmar grip reflex. Inspect hands, finger, & elbows

Hips
Barlow’s test

Ortolani

Legs Size and symmetry (check for tibial torsion)

Spine Pigmented spots (Mongolian spots- normal)

Hairy patches

XII. Neurologic
Mental status
Ask the child a few questions to assess the following:

1. Level of Observe if child is alert, lethargic, or unconscious. If the child is asleep, see if he/she can
consciousness easily be awakened.

2. Orientation to Ask his/her name and the relative’s name (person),

person, place,
and time* Ask if he knows where he is (place), and if he knows what time, day, or month it is (time)

3. Memory* Recent or short-term memory covers minutes, hours, or days; Ex. ask patient to repeat 3
items (ex, ball, fish, box)

Remote or long-term memory refers to intervals of years: Ex. Ask about his favorite school
 activity or family activity done last year.

4. Language* Comprehension should be tested first with the use of three part commands such as "close
your eyes, turn your head to the left and touch your left hand to your right ear" or simpler
commands.

Ask the child to name objects, pictures, or colors.

Ask the child to read. (Flash cards will be provided)

* # 2, 3, and 4 should be assessed based on the child’s expected ability depending on his/her age.

Cranial nerves
Cranial Test:
Nerves

I - Olfactory

II- Optic Use of the Snellen chart after age 3 years. (This just need to be mentioned by the student)

Test visual fields as for an adult. The parent may need to hold the child’s head.

1. Stand two feet in front of the patient and have them look into your eyes.

2. Hold your hands about one foot away from the patient's ears, and wiggle a finger on one hand.

3. Ask the patient to indicate which side they see the finger move.

4. Repeat two or three times to test both temporal fields.

5. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the
opposite eye with a card.

Test Pupillary Reactions to Light:

1. Dim the room lights as necessary.

2. Ask the patient to look into the distance.

3. Shine a bright light obliquely into each pupil in turn.

4. Look for both the direct (same eye) and consensual (other eye) reactions.

5. Record pupil size in mm and any asymmetry or irregularity

Fundoscopic examination (if child is cooperative). The margins, color and shape of the optic disc should be
noted. In early papilledema there is blurring of the margins, venous distention and hyperemia of the optic
nerve head

III - Observe for ptosis

Oculomotor,
IV -Trochlear, Test the extraocular movements
and VI - 1. Have the child track a light or an object (a toy is preferable). A parent may need to hold the child’s
Abducens head.

2. Check gaze in the six cardinal directions using a cross or "H" pattern.

3. Pause during upward and lateral gaze to check for nystagmus.

4. Check convergence by moving your finger toward the bridge of the patient's nose

V - Trigeminal Sensory: Play a game with a soft cotton ball to test sensation on the forehead, cheeks, and jaw on each
side.

Test corneal reflex by asking the child to look up and away. From the other side, touch the cornea lightly
with a fine wisp of cotton. Look for the normal blink reaction of both eyes.

Motor: Palpate the temporal and masseter muscles. Have the child clench the teeth and do the act of
chewing and note the strength of muscle contraction

VII - Facial Have the child “make faces” or imitate you as you make faces (include raise eyebrows, close eyes, smile,
frown, show teeth, puff out cheeks), and observe symmetry and facial movements.

In a crying child, observe forceful eye closure and compare on each side. In the patient at rest, observe for
widened palpebral fissure on the affected side (weakness of orbicularis oculi). Lower facial weakness
 manifests as a loss or decrease of the nasolabial fold on the affected side.

VIII - Acoustic Perform auditory testing after age 4 years. Whisper a word or command behind the child’s back and have
the child repeat it.

IX – Glosso- Ask the child to swallow and to say "Ah"

pharyngeal
Observe movement of the uvula and soft palate.
X- Vagus
Describe how to elicit gag reflex. (No need to demonstrate)

XI- Spinal Have the child push your hand away with his head. Have the child shrug his shoulders while you push
accessory down with your hands to “see how strong you are.”

XII- Ask child to protrude tongue and move tongue from side to side.
Hypoglossal

Motor strength
Flexion at the elbow

Extension at the elbow

Extension at the wrist

“Grip”: Ask to squeeze two of your fingers as hard as possible

Finger abduction

Opposition of the thumb

Flexion at the hip

Adduction at the hips

Abduction at the hips

Extension at the knee

Flexion at the knee

Dorsiflexion at the ankle

Tendon reflex
Biceps

Triceps

Brachioradialis

Knee

Ankle

Clonus Support the knee in a partly flexed position. With the patient relaxed, quickly dorsiflex the foot.
Observe for rhythmic oscillations.

Babinski Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. Note
movement of the toes, normally flexion (withdrawal). Extension of the big toe with fanning of the
other toes is abnormal. This is referred to as a positive Babinski.
Coordination and gait
Rapid alternating movements of the hands (Dysdiadoschokinesia)

Finger-nose test (Dysmetria)

Romberg

1. Be prepared to catch the patient if they are unstable.

2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support.

3. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Gait: Observe the child’s gait while the child is walking and, optimally, running. Note any asymmetries, weakness,
undue tripping or clumsiness. Ask a cooperative child to do heel-to-toe walk, hop, and jump.