A pediatric history taking template for undergraduate and postgraduate students

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PEDIATRIC HISTORY SHEET
General Points: -
 Introduce yourself.Always be gentle and polite.
 Always wash your hands before examiningthe patient.
 Pleasedon’t talk on mobileor among yourself Infront of the patient.
 Approach from rightside.
 Always explain and take consent of parents.
 Always have a female attendant in addition to patient’s mother whileexaminingan adolescent
female.
 Always keep some toys in pocket (should not have chokinghazard or button cells or harmful in any
other way).
Demographic information: -
Full Name: -
Caste/Religion: -
Age & Date of Birth: -
Sex: -
Address/Also ask native in case of migrants: -
Mobile number: -
Date of Admission/Date of History Taking: -
Informant and his/her reliability: -
Chief Complaints: -
3-4 maximum, in chronological order of the appearance of symptoms
Origin Duration Progress: -
History of present illness in details with negative history
Origin
Duration
Progress
Severity
Aggravating or Reliving factors

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Treatment History: -
Any allopathic/non allopathic medicines /self-medications/surgery done for the present
complaints. How much relief obtained after the treatment?
Birth History: -
 Prenatal: - for example, mother received antenatal care, no history of fever or skin
rashes during pregnancy, no history of any teratogenic drug intake
 Natal: - for example full term normal vaginal delivery, cried soon after birth
 Postnatal: -for example, uneventful, no NICU admission.
Sibling History: -
No of sibs/Whether they are healthy or not/Vaccinated or not/Any sibling deaths
Past History: -
Similar complaints/Admission/Major illness/Blood transfusion/Surgery/
Tuberculosis/Measles /seizures/G6PD deficiency (if belonging to certain castes where g6pd
is common.)
Allergies: -
Drug Allergy/Food Allergy/Inhalant Allergy
Family History: -
Any major illness/Similar illness/Tuberculosis/Hereditary illness
Make Pedigree chart, at least 2 generations, more if hereditary disease is suspected

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Socioeconomic History: -
• Socio economic class as per modified Kuppuswamy classification
• Educational background
• Number of persons living in the family (mention if pets are there)
• Per capita income
• Type of house (kutcha/pukka), whether toilet in the house or not.
• Indoor and outdoor pollution
• Sanitation
Personal History: -
Any addictions, ask in case of adolescents only.
Dietary History: -
• Information about Exclusive BF & Complementary feeding.
• 24 hr dietary recall.
• Pre illness and post illness.
Calories Protein
Total
Expected (RDA as
per ICMR)
Inference
Any dietary
restrictions
Developmental History: -
Gross Motor Fine Motor Social Language Vision Hearing
Inference

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Anthropometry/Auxology:-
Actual Expected Inference
Weight
Height/Length
Head circumference till 5 years of age
Chest circumference till 3 years of age
Mid arm circumference till 5 years of
age
Upper segment/Lower segment ratio
Always attach growth charts (W/A,H/A,W/H and Head circumference). Label growth chart
with patient’s name, age (dob), gender.
Immunization History: -
As per national immunization program.
BCG scar present or not.
Received any additional vaccines.
Any AEFI

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General Examination
Vital signs: - temperature/pulse rate/respiratory rate/blood pressure/capillary filling
time/oxygen saturation/blood sugar
Head to Toe examination of the child
Try to include PICCLE (pallor/icterus/clubbing/cyanosis/lymphadenopathy/edema).
Systemic Examination:-
Examine the relevant systemfirst.
Made by Dr Kaushik Barot
Pediatrician and Pediatric Gastroenterologist
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Degrees of Consanguinity: -
Degree of Consanguinity Percentage of shared genes Relationship
First degree 50 % Parents, children & siblings.
Second degree 25% Grandparents, uncles,
aunts, nephews, nieces and
half siblings.
Third degree 12.5 % First degree cousins.
3.1% Second degree cousins.