MEDICAL HISTORY FORM

PEDIA
NAME: AGE: DATE:
TIME:
SEX: [_] Male ADDRESS:
[_] Female

RELIGION: BIRTHDATE:
RACE:
NUMBER AND DATE OF HOSPITAL ADMISSION/S: PLACE OF BIRTH:

INFORMANT: RELIABILITY (%):

REFERRAL:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

REVIEW OF SYMPTOMS
General Genitourinary
[] Weight loss ________ [] kg [] lbs [ ] Dysuria
[] Weight gain ________ []kg []lbs [ ] Increased frequency of urination
[] Activity level ____________________ [ ] Decreased frequency of urination
Appetite : [ ] Enuresis
[] Good ; [] Poor [ ] Edema of hands and feet
[] Delay in Growth
In a prepubertal female:
Cutaneous [ ] Vaginal discharge
[] Rash [ ] Itching
[] Pigmentation
[] Hair loss In a pubertal and adolescent female:
[] Acne History of menstrual periods :
[] Pruritus Onset _______________________
Frequency __________________
Regularity __________________
Duration____________________
Pain ______________________ ; Pain scale [ / ]
Date of last menstruation: _____/_____/_____
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PEDIA
Head (including eyes, ears, nose, mouth and
throat) Endocrine
[] Headache [ ] Breast asymmetry
[] Dizziness [ ] Pain
[] Lacrimation [ ] Discharge
[] Aural discharge [ ] Palpitations
[] Nasal discharge [ ] Cold/heat intolerance
[] Epistaxis [ ] Polyuria
[] Toothache [ ] Polyphagia
[] Salivation [ ] Polydipsia
[] Sore throat
Nervous/Behavioral
Cardiovascular [ ] Tremors
[] Orthopnea [ ] Sleep problems
[] Cyanosis [ ] Convulsions
[] Easy Fatiguability [ ] Weakness or paralysis
[] Fainting spells [ ] Mental deterioration
[ ] Personality or behavioral changes
Respiratory [ ] Memory loss
[ ] Chest pain [ ] Eating problems
[ ] Cough [ ] School failures
[ ] Colds [ ] Mood changes
[ ] Difficulty of breathing [ ] Temper outbursts
[ ] Hallucinations
Gastrointestinal
[ ] Diarrhea Musculoskeletal
[ ] Constipation [ ] Bone, Joint or muscle pain or swelling
[ ] Vomiting [ ] Limitation of motion
[ ] Jaundice [ ] History of trauma; Indicate: ______________________
[ ] Passage of worms [ ] Stiffness
[ ] Abdominal pain [ ] Limping
[ ] Encopresis
[ ] Food intolerance Hematopoeietic
[ ] Pica [ ] Bleeding manifestations
[ ] Pallor
[ ] Easy bruisability

PAST PERSONAL HISTORY:

A. GESTATIONAL
Mother’s age during pregnancy: ________ Hepa B Screening
OB Score: [ ] Positive [ ] Negative

______________________________________________
Infections: HIV Screening
Onset: [ ] Positive [ ] Negative
Duration:
Severity: [ ] Exposure to radiation
[] Intake of drugs ___________________________ [ ] Use of Ilicit drugs
[ ] Use of abortifacients
Prenatal check-ups:
[ ] Regular [ ] Irregular

Vitamin Intake:
[ ] Multivitamins [ ] Folic Acid [ ] Iron

Maternal health
[ ] Poor
[ ] Smoked during pregnancy
[ ] Drank alcohol during pregnancy
[ ] Others: ___________________________
[ ] Good
 MEDICAL HISTORY FORM
PEDIA
B. BIRTH
[ ] Mature [ ] Premature [ ] Post-Mature Birth weight:

Manner of Delivery Person who attended during delivery:

[ ] Normal Spontaneous Delivery [ ] Doctor/ OB
[ ] Caesarian Section [ ] Midwife
Reason:_________________________ [ ] Nurse
[ ] Others: ______________________________

C. Neonatal
Respiration Complications:
[ ] Spontaneous respiration [ ] Jaundice
[ ] Required resuscitation [ ] Convulsions
[ ] Difficulty breathing
Cry [ ] Poor feeding
[ ] Immediate [ ] Medications given
[ ] Delayed Specify:
[ ] Extended hospital/NICU stay
Activity Duration:
[ ] Some flexion [ ] Congenital abnormalities
[ ] Active and spontaneous movements of limbs [ ] Birth injury

[ ] Cyanosis
[ ] Pallor
D. FEEDING/NUTRITIONAL
Infant (<2 yo) Childhood and adolescence (2-20 yo)
Picky eater
[ ] Breastfed [ ] Yes [ ] No
Frequency of breast feeding:
[ ] Adequate Appetite prior to illness
[ ] Inadequate (<8times/day) [ ] Normal [ ] Poor
Latching
[ ] Good [ ] Poor

[ ] Mixed/Milk Formula
Reason:__________________________
Formula:
Dilution:
Amount given per day:
[] Bottle-fed [ ] Cup-fed

Complementary food:
Age introduced:
Frequency of feeding per day:

SAMPLE DIET: 24 HOUR DIET RECALL:

Breakfast

Lunch

Dinner

Snacks
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PEDIA
E. DEVELOPMENTAL (Age 1 -5)
2 months
Social and Emotional Language/Communication
[ ] Smiles at people [ ] Coos, makes gurgling sounds
[ ] Can briefly calm himself (may bring hands to [ ] Turns head toward sounds
mouth and suck on hand) [ ] Baby raising head and chest when lying on stomach
[ ] Tries to look at parent

Cognitive (learning, thinking, problem-solving) Movement/Physical Development

[ ] Can hold head up and begins to push up when lying on
[ ] Pays attention to faces tummy
[ ] Begins to follow things with eyes and recognize [ ] Makes smoother movements with arms and legs
people at a distance
[ ] Begins to act bored (cries, fussy) if activity
doesn’t change
4 MONTHS
Social and Emotional Language/Communication
[ ] Smiles spontaneously, especially at people [ ] Begins to babble
[ ] Likes to play with people and might cry when [ ] Babbles with expression and copies sounds he hears
playing stops [ ] Cries in different ways to show hunger, pain, or being
[ ] Copies some movements and facial expressions, tired baby on floor with toy
like smiling or frowning
Movement/Physical Development
Cognitive (learning, thinking, problem-solving) [ ] Holds head steady, unsupported
[ ] Lets you know if she is happy or sad [ ] Pushes down on legs when feet are on a hard surface
[ ] Responds to affection [ ] May be able to roll over from tummy to back
[ ] Reaches for toy with one hand [ ] Can hold a toy and shake it and swing at dangling toys
[ ] Uses hands and eyes together, such as seeing a [ ] Brings hands to mouth
toy and reaching for it [ ] When lying on stomach, pushes up to elbows
[ ] Follows moving things with eyes from side to
side
[ ] Watches faces closely
[ ] Recognizes familiar people and things at a
distance
18 MONTHS
Social and Emotional Cognitive (learning, thinking, problem-solving)
[ ] Likes to hand things to others as play [ ] Knows what ordinary things are for; for example,
[ ] May have temper tantrums telephone, brush, spoon
[ ] May be afraid of strangers [ ] Points to get the attention of others
[ ] Shows affection to familiar people [ ] Shows interest in a doll or stuffed animal by pretending
[ ] Plays simple pretend, such as feeding a doll to feed
[ ] May cling to caregivers in new situations [ ] Points to one body part
[ ] Points to show others something interesting [ ] Scribbles on his own
[ ] Explores alone but with parent close by [ ] Can follow 1-step verbal commands without any
[ ] Toddler eating you from a blue bowl gestures; for example, sits when you say “sit down”
Language/Communication Movement/Physical Development
[ ] Says several single words [ ] Walks alone
[ ] Says and shakes head “no” [ ] May walk up steps and run
[ ] Points to show someone what he wants [ ] Pulls toys while walking
[ ] Can help undress herself
[ ] Drinks from a cup
[ ] Eats with a spoon
2 YEARS
Social and Emotional Language/Communication
[ ] Copies others, especially adults and older [ ] Points to things or pictures when they are named
children [ ] Knows names of familiar people and body parts
[ ] Gets excited when with other children [ ] Says sentences with 2 to 4 words
[ ] Shows more and more independence [ ] Follows simple instructions
[ ] Shows defiant behavior (doing what he has been [ ] Repeats words overheard in conversation
told not to) [ ] Points to things in a book
[ ] Plays mainly beside other children, but is [ ] 2 year old playing with big ball
beginning [ ] to include other children, such as in
chase games
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PEDIA
Movement/Physical Development
Cognitive (learning, thinking, problem-solving) [ ] Stands on tiptoe
[ ] Finds things even when hidden under two or [ ] Kicks a ball
three covers [ ] Begins to run
[ ] Begins to sort shapes and colors [ ] Climbs onto and down from furniture without help
[ ] Completes sentences and rhymes in familiar [ ] Walks up and down stairs holding on
books [ ] Throws ball overhand
[ ] Plays simple make-believe games [ ] Makes or copies straight lines and circles
[ ] 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
3 YEARS
Social and Emotional Language/Communication
[ ] Copies adults and friends [ ] Follows instructions with 2 or 3 steps
[ ] Shows affection for friends without prompting [ ] Can name most familiar things
[ ] Takes turns in games [ ] Understands words like “in,” “on,” and “under”
[ ] Shows concern for crying friend [ ] Says first name, age, and sex
[ ] Understands the idea of “mine” and “his” or [ ] Names a friend
“hers” [ ] Says words like “I,” “me,” “we,” and “you” and some
[ ] Shows a wide range of emotions plurals (cars, dogs, cats)
[ ] Separates easily from mom and dad [ ] Talks well enough for strangers to understand most of
[ ] May get upset with major changes in routine the time
[ ] Dresses and undresses self [ ] Carries on a conversation using 2 to 3 sentences
[ ] Toddler hugging doll
Movement/Physical Development
Cognitive (learning, thinking, problem-solving) [ ] Climbs well
[ ] Can work toys with buttons, levers, and moving [ ] Runs easily
parts [ ] Pedals a tricycle (3-wheel bike)
[ ] Plays make-believe with dolls, animals, and [ ] Walks up and down stairs, one foot on each step
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
4 YEARS
Social and Emotional Language/Communication
[ ] Enjoys doing new things [ ] Knows some basic rules of grammar, such as correctly
[ ] Plays “Mom” and “Dad” using “he” and “she”
[ ] Is more and more creative with make-believe [ ] Sings a song or says a poem from memory such as the
play “Itsy Bitsy Spider” or the “Wheels on the Bus”
[ ] Would rather play with other children than by [ ] Tells stories
himself [ ] Can say first and last name
[ ] Cooperates with other children [ ] Child throwing ball
[ ] Often can’t tell what’s real and what’s make-
believe
[ ] Talks about what she likes and what she is Movement/Physical Development
interested in [ ] Hops and stands on one foot up to 2 seconds
[ ] Catches a bounced ball most of the time
Cognitive (learning, thinking, problem-solving) [ ] Pours, cuts with supervision, and mashes own food
[ ] Names some colors and some numbers
[ ] 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
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PEDIA
[ ] Tells you what he thinks is going to happen next
in a book

5 YEARS
Social and Emotional Language/Communication
[ ] Wants to please friends [ ] Speaks very clearly
[ ] Wants to be like friends [ ] Tells a simple story using full sentences
[ ] More likely to agree with rules [ ] Uses future tense; for example, “Grandma will be here.”
[ ] Likes to sing, dance, and act [ ] Says name and address
[ ] Shows concern and sympathy for others
[ ] Is aware of gender Movement/Physical Development
[ ] Can tell what’s real and what’s make-believe [ ] Stands on one foot for 10 seconds or longer
[ ] Shows more independence (for example, may [ ] Hops; may be able to skip
visit a next-door neighbor by himself [adult [ ] Can do a somersault
supervision is still needed]) [ ] Uses a fork and spoon and sometimes a table knife
[ ] Is sometimes demanding and sometimes very [ ] Can use the toilet on her own
cooperative Swings and climbs
[ ] 5 year old playing guitar

Cognitive (learning, thinking, problem-solving)

[ ] Counts 10 or more things
[ ] 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
OTHERS
Urinary continence: [ ] Phobias, specify
Day [ ] Normal [ ] Abnormal [ ]Pica
Night [ ] Normal [ ] Abnormal [ ] Night terror
[ ] Toilet training [ ]Sleep disturbances
[ ] Temper tantrums [ ] Behavioral problems
[ ] Head banging
Age 6 – 10
STAGE MALES FEMALES
STAGE I: PREPUBSCENT
Pubic Hair [ ] Yes [ ] No [ ] Yes [ ] No
Bone age <12 (M), 11 (F) years [ ] Yes [ ] No [ ] Yes [ ] No
Breast Development [ ] Yes [ ] No
STAGE II
Pubic Hair [ ] None [ ] Minimal [ ] None [ ] Minimal
Bone age < 12 (M), 11 (F) years [ ] Yes [ ] No [ ] Yes [ ] No
Breast Buds [ ] Present [ ] None
STAGE III: PUBESCENT
Pubic Hair over penis/mons [ ] Yes [ ] No [ ] Yes [ ] No
Voice Changes [ ] Yes [ ] No
Bone age of 13-14 yrs (M), <11yrs (F) [ ] Yes [ ] No [ ] Yes [ ] No
Axillary hair [ ] Yes [ ] No
Breast enlargement [ ] Yes [ ] No
STAGE IV
Adult pubic hair [ ] Yes [ ] No [ ] Yes [ ] No
Axillary hair [ ] Yes [ ] No
Bone age of 13-14yrs (M), 12-13yrs [ ] Yes [ ] No [ ] Yes [ ] No
(F) [ ] Yes [ ] No [ ] Yes [ ] No
Areola enlargement
STAGE V: POSTPUBESCENT
As adult [ ] Yes [ ] No [ ] Yes [ ] No
Bone age of 14-16yrs (M), 13-14yrs [ ] Yes [ ] No [ ] Yes [ ] No
(F)
 MEDICAL HISTORY FORM
PEDIA
Age 10 – 20
Home
Who lives with the teen?
Own room?
Relationship at home?
How often has the family moved?
Who does the teen turn to if there are problems?
What happens if parents are angry?
Education/Employment
Grade/Year in school
School grades
Favorite subject
Best subject?
Worst subject?
Does the teen feel safe at school?
Who does the teen turn to if there are problems?
Future goals/ambition?
Failures? [ ] Yes [ ] No
Repeated classes? [ ] Yes [ ] No
Truancy [ ] Yes [ ] No
Activities
What does the teen do for fun?
Who are the teen’s peers?
Does teen belong in any organized sports/clubs?
Hobbies?
Church attendance?
What does teen do with his peers?
With family?
Does then have a car? [ ] Yes [ ] No
Does teen use seatbelts? [ ] Yes [ ] No
Sexuality
Orientation [ ] Male [ ] Female [ ] Gay [ ] Bisexual [ ] Others:
Sexual Experience [ ] Sexually active [ ] Not active
Number of partners
Masturbation [ ] Yes [ ] No
History of pregnancy or abortion [ ] Yes [ ] No
History of STIs [ ] Yes [ ] No
Contraception [ ] Yes [ ] No Type:
History of physical/sexual abuse? [ ] Yes [ ] No
Suicide/Depression
Sleep disorder [ ] Yes [ ] No
Fatigue [ ] Yes [ ] No
Appetite changes [ ] Yes [ ] No
Feeling of hopelessness [ ] Yes [ ] No
Feeling of isolation [ ] Yes [ ] No
Feeling of boredom [ ] Yes [ ] No
Withdrawn [ ] Yes [ ] No
History of past suicide attempts [ ] Yes [ ] No
History of family suicides [ ] Yes [ ] No
History of recurrent accidents [ ] Yes [ ] No
Preoccupation with death [ ] Yes [ ] No
Suicidal ideation [ ] Yes [ ] No
Period
Date of first onset
Date of last menstruation
Regularity [ ] Regular [ ] Irregular Pain [ ] Present [ ] Absent
Warning signs of ADHD Warning signs of Autism

• [ ] Difficulty paying attention (inattention) • [ ] Problems with eye contact

• [ ] Being overactive (hyperactivity) • [ ] No response to his or her name
• [ ] Acting without thinking (impulsivity) • [ ] Problems following another person's gaze or pointed
• finger to an object (or "joint attention")
• Warning signs of learning disability • [ ] Poor skills in pretend play and imitation
• [ ] Problems reading and/or writing • [ ] Problems with nonverbal communication
• [ ] Problems with math
 MEDICAL HISTORY FORM
PEDIA
• [ ] Poor memory
• [ ] Problems paying attention
• [ ] Trouble following directions
• [ ] Clumsiness
• [ ]Trouble telling time
• [ ] Problems staying organized

F. PAST ILLNESSES
Contagious diseases Injuries
[ ] Measles [ ] Mumps [ ] Yes [ ] No
[ ] Varicella [ ] Pertussis Date:
[ ] Others: Reason:
Medication:
Hospitalization
[ ] Yes [ ] No [ ] Allergy [ ] Asthma
Date: [ ] Eczema
Duration:
Reason:

Medication:

Operations:
[ ] Yes [ ] No
Date:
Reason:
Medication:
IMMUNIZATION (AS RECOMMENDED BY DOH)
RECOMMENDED AGE
VACCINE DISEASE AT 1½ 2½ 3½ 9 1
AVOIDED BIRTH mos mos mos mos yr
BCG Tuberculosis
HEPATITIS Hepatitis B
PENTAVALENT Diphtheria
VACCINE (DPT-Hep B- Tetanus, Hepa B,
HiB) Pertussis,
Pneumonia,
Meningitis
ORAL POLIO VACCINE Polio
INACTIVATED POLIO Polio
VACCINE
PNEUMOCOCCAL Pneumonia,
CONJUGATE VACCINE Meningitis
(PCV)
MEASLES, MUMPS, Measles, Mumps.
RUBELLA (MMR) German Measles
Place of Administration: Untoward Reactions:
[ ] Tuberculin testing done
G. FAMILY MEDICAL HISTORY
Father’s name: Age: [ ] Alive [ ] Dead
Physical Health: Cause of death:
Nature of Symptom:
Mental health: History of consanguinity:

Mother’s name: Age: [ ] Alive [ ] Dead

Physical Health: Cause of death:
Nature of Symptom:
Mental health: History of consanguinity:
 MEDICAL HISTORY FORM
PEDIA
Name of Sibling # 1: Age: [ ] Alive [ ] Dead
Physical Health: Cause of death:
Nature of Symptom:
Mental health: History of consanguinity:

Name of Sibling # 2: Age: [ ] Alive [ ] Dead

Physical Health: Cause of death:
Nature of Symptom:
Mental health History of consanguinity:

Name of Sibling # 3: Age: [ ] Alive [ ] Dead

Physical Health: Cause of death:
Nature of Symptom:
Mental health History of consanguinity:

Familial Illness
[ ] Tuberculosis [ ] Rheumatic fever
State: [ ] Allergy
Degree of contact with px: [ ] Hematologic diseases
[ ] Diabetes Mellitus [ ] Mental retardation
[ ] Syphilis [ ] Congenital defects
[ ] Cancer [ ] Others:
[ ] Epilepsy

FAMILY GENOGRAM (INCLUDE AT LEAST 3 GENERATIONS)

Legend:
 MEDICAL HISTORY FORM
PEDIA
H. Personal and Social History
Primary caregiver of the child: Economic circumstances

Living circumstances: Working members of the family:

Place and Nature of dwelling: Parent’s occupation
Number of household members: Mother:
Father:
[ ] Exposure to cigarette smoke
[ ] Exposure to pollution _____________________ Sources of fund:

Garbage disposal: _____________________________

Sewage disposal:_______________________________

Water source: __________________________________

[ ] Presence of risk for development of certain diseases: