SILLIMAN UNIVERSITY MEDICAL SCHOOL Menstrual: Allergies:

DEPARTMENT OF PEDIATRICS Menarche _________________________☐Regular ☐Irregular __________________________________________________

History and Physical Exam Days/cycle___________pads/day __________☐Dysmenorrhea __________________________________________________
LMP ________________________________________________ __________________________________________________
Patient’s Name___________________________________________ Age/Sex ____________________ Date of Birth __________
Address ________________________________________________ Citizenship __________________ Religion ______________ Past Illness:
Informant ________________________________________ % Reliability ________________ Admitted for the ___________ time ____________________________________________________________________________________________________________
CHIEF COMPLAINT: ____________________________________________________________________________________________________________
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HISTORY OF PRESENT ILLNESS ____________________________________________________________________________________________________________
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-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- IMMUNIZATION FAMILY HISTORY
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- BCG (at birth then 7 yrs old) 1 dose Age Occupation State of health
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- DPT (2, 4 , 6 mos) 3 doses Mother
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- IPV/OPV (2, 4, 6 mos) 3 doses Father
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Hep B (at birth, 6, 10, 14) 3 doses Siblings
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Hib (2, 4 6 mos)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Measles (6-9 mos) 1 dose
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- MMR (15 mos) 1 dose
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Heredofamilial
Others
REVIEW OF SYSTEMS: Diseases:
GENERAL RESPIRATORY  Discharge  Temper outburst
 Weight change  Chest pain  Enuresis  Hallucinations SOCIOECONOMIC HISTORY ENVIRONMENTAL HISTORY
 Appetite  Cough  Edema MUSCULOSKELETAL ____________________________________________________ __________________________________________________
 Activity level  Dyspnea ENDOCRINE  Bone pain ____________________________________________________ __________________________________________________
 Delay in growth CARDIOVASCULAR  Breast asymmetry  Myalgia ____________________________________________________ __________________________________________________
CUTANEOUS  Orthopnea  Breast pain  Arthralgia
 Rashes  Cyanosis  Breast discharge  Swelling PHYSICAL EXAMINATION
 Pigmentation  Fatigue  Cold/ heat intolerance  Limited motion General Survey: _______________________________________________________________________________________________
 Hair loss  Fainting spells  Polyuria  Stiffness
 Acne ____________________________________________________________________________________________________________
GIT  Polydipsia  Limping
 Pruritus  Vomiting  Polyphagia HEMATOPOIETIC
Vital Signs: T:_____________ CR: _________________RR: _______________ BP: _______________ SaO2:_______________
HEENT  Diarrhea/constipation NERVOUS/ BEHAVIORAL  Pallor Anthropometric data: Wt: ________ Ht/Lt: __________ BMI:__________ HC: ___________ CC: ____________ AC: _________
 Headaches  Encopresis  Tremors  Bleeding Skin: ________________________________________________________________________________________________________
 Dizziness  Passage of worms  Sleep problems  Bruising ____________________________________________________________________________________________________________
 Visual difficulty  Abdominal pain  Convulsions PREPUBERTAL HEENT:______________________________________________________________________________________________________
 Lacrimation  Jaundice  Weakness  Discharge
 Hearing ____________________________________________________________________________________________________________
 Food intolerance  Mental deterioration  Itching
 Discharges  Pica  Personality changes PUBERTAL
Neck: ______________________________________________________________________________________________________
 Epistaxis GUT  Memory loss  Menstrual period C/L: ________________________________________________________________________________________________________
 Toothache  Color of urine  Eating problem  Onset ____________________________________________________________________________________________________________
 Salivation  Burning  School failures  Frequency CVS: ________________________________________________________________________________________________________
 Sore throat  Frequency  Mood changes ____________________________________________________________________________________________________________
GIT: ________________________________________________________________________________________________________
PERSONAL HISTORY:
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Gestational: Age of mother __________OB Score _____________ Neonatal:_________________________________________
GUT: _______________________________________________________________________________________________________
Prenatal check-up ______________________________________ __________________________________________________
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Maternal illness _______________________________________ Feeding(<2yo): Breastfeeding _________________________
Ext: ________________________________________________________________________________________________________
Medications taken: _____________________________________ Milk formula _______________________________________
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Birth: Delivered at ___________________ by ________________ Semi solids ________________________________________
CNS:________________________________________________________________________________________________________
☐Full term ☐ Preterm BS: _____________ BW: ______________ Food intolerance ____________________________________
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Manner of delivery ____________ AS:__________ Rank:_______ Supplements _______________________________________
Development/Behavioral History
Admitting
_____________________________________________________ HEADSS (> 10 yrs old)
Impression:__________________________________________________________________________________________________
_____________________________________________________ Home Education Eating Activities Drugs Sexual Suicidal
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