- Introductory information
- Presenting complaint
- History of presenting complaint
- Past medical, surgical history: birth, nutritional,
- Family history
- Social, personal history
- Drug history
- Systems review
- History tips
- Introduce, establish rapport.
- Name, age, gender.
- Person giving the history (parent, etc).
- Description of the presenting complaint, in chronological order.
- Including whether came in through casualty or admitted by GP.
- Time course: seasonal or diurnal fluctuation.
- Exacerbating factors: foods.
- Referral by GP vs. came in through casualty.
- Relevant negatives.
- If using slang, ask for clarification.
- Length of gestation.
- Age and parity of mother at delivery.
- Any maternal insults [alcohol, smoking] or illnesses during gestation.
- Where born: city, hospital.
- Birth weight, mode of delivery, difficulties in delivery.
- Resuscitation, intensive care requirement at birth.
- Cyanosis, pallor, jaundice, convulsions, birthmarks, malformations, feeding or
- Apgar score at birth if known.
- How baby was fed in first few days.
- Whether child went home with mother.
- Breast-fed vs. bottle-fed
- When breast started, stopped.
- If formula: type, amount, pre-mixed vs concentrate [and dilution used].
- Vitamin supplements.
- Age when beikost started.
- Appetite and growth.
- Current diet.
- Past illnesses, operations.
- Childhood illness, obs/gyn.
- Tests and treatment prescribed for these.
- Problems with the anesthetic in surgery.
- Start of school attendance.
- Where attend school.
- Special needs requirements.
- Impact of symptoms: absent school days.
- The current complaint in parents/ siblings: health, cause of death, age of onset, age of
- Parents/siblings: age, health, where living.
- Height and weight of parents.
- Hereditary dz suspected: do a family tree.
- Age, occupation of parents.
- Race and migration of parents [if relevant].
- Any others at daycare/ school with same complaint.
- Travel: where, how lived when there, immunization/ prophylactic status when went.
- Does the child live at home, and with whom [include siblings].
- Smokers in the home.
- Pets in the home.
- "Is there some things that worry you about the symptoms you child is having?"
- Prescriptions currently on: dose, when started, what for.
- Alternative medications.
- Allergies, and reaction of each:
- Eczema, asthma, hay fever, hives.
- Drugs, foods, dyes.
- Use "the father" or "the mother" instead of "your husband"
or "your wife", as current spouse may not be the genetic parent, also avoids
issue of a divorce/separation.
- Parents may use slang. Ask "do you mean..." for clarification as needed.
- Ask if the temperature was actually measured, and if so, what it was.
Pediatrics Exam »