Paediatrics history taking sheet for undergraduate medical students

1. PAEDIATRIC HISTORY
PATIENT PROFILE
NAME:_______________________________________
SEX: ▢MALE ▢FEMALE
AGE:__________________________
WEIGHT:________________________
ADDRESS:______________________________
DATE OF ADMISSION______________________
MODE OF ADMISSION: ▢OPD ▢EMERGENCY
CHIEF COMPLAINTS
1)_______________________________________________________________________
2)_______________________________________________________________________
3)_______________________________________________________________________
4)_______________________________________________________________________
5)_______________________________________________________________________
6)_______________________________________________________________________
HOPI
1)________________________________________________________________________
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2)________________________________________________________________________
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3)________________________________________________________________________
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4)________________________________________________________________________
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5)________________________________________________________________________
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6)________________________________________________________________________
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COMMONCOMPLAINTS HOPI:

2. ▢PAIN
1)SITE___________________________________________________________
2)ONSET_________________________________________________________
3)CHARACTER:_____________________________________________
4)RADIATION:___________________________________________
5)ASSOCIATED SYMPTOMS:___________________________________
6)TIMING:_______________________________________
7)EXACERBATING AND RELIEVING
FACTORS:_____________________________________
8)SEVERITY:_______________________________________________
▢FEVER:
1)MODE OF ONSET: ACUTE▢ GRADUAL▢
2)RIGORS▢CHILLS▢
3)GRADE: HIGH▢ LOW▢
4) PATTERN: CONTINUOUS▢ REMITTENT▢ INTERMITTENT▢ RELAPSING▢
4A)EPISODES OF CONVULSIONS☐
5)ASSOCIATED SYMPTOMS:____________________________________________________
▢VOMITING:
1)DURATION:________________________________________________________
2)FREQUENCY:_____________________________________________________
2a)PROJECTILE ☐YES ☐NO
3a)RELATION WITH FEEDING ☐YES ☐NO
3)COLOUR,SMELL:____________________________________________________
4)ASSOCIATED SYMPTOMS:_______________________________________________
▢DIARRHEA
1)DURATION:____________________________________________________
1A)COLOUR:________________________________________
1B)☐BLOOD ☐MUCUS
2)FREQUENCY:__________________________________________________
3)QUANTITY:____________________________________________________
4)CONSISTENCY:________________________________________________
5)TENESMUS▢
5A)VOMITING ☐YES ☐NO
5)OTHER SYMPTOMS:____________________________________________
6)CHILD THIRSTY OR DRINK EAGERLY ☐YES ☐NO
▢DYSPNEA
▢EXERTIONAL:
1)DURATION:______________________________________________________
2)ON HOW MUCH EXERTION:___________________________________________
3)PROGRESS:_____________________________
4)PND▢
5)ORTHOPNEA▢
6)OTHER SYMPTOMS:__________________________________________________
▢AT REST
1)AGE OF ONSET:____________________________________________________

3. 2)WHEEZE▢
3)FREQUENCY, SEVERITY,
DURATION:___________________________________________
4)OTHER SYMPTOMS:_________________________________________________________
▢COUGH
1)DURATION:__________________________
2)FREQUENCY,SEVERITY_______________________________
2A)CHARACTER_________________________________________
2B)TIMING___________________________________
3)DRY▢PRODUCTIVE▢
4)QUANTITY AND COLOUR OF SPUTUM:
5)HEMOPTYSIS▢
6)OTHER SYMPTOMS:_______________________________________________________
☐CONVULSIONS:
1)☐FIRST ☐RECURRENT
2)☐FIBRILE ☐AFIBRILE
3)ANY SYSTEMIC ILLNES____________________________
4)☐HISTORY OF TRAUMA
5)☐HISTORY OF DRUG INTAKE___________________
6)BIRTH HISTORY_____________________________
BIRTH HISTORY
ANTENATAL HISTORY:
1)NUTRITIONAL STATUS OF MOTHER ☐GOOD ☐POOR
2)MATERNAL INTAKE OF ☐IRON ☐MULTIVITAMINS ☐DRUGS_________________
3)☐MATERNAL ILLNESS DURING PRAGNANCY___________________
4)EXPOSURE TO RADIATIONS ☐YES ☐NO
5)ANY ABORTIONS OR STILLBIRTHS ☐YES ☐NO
NATAL HISTORY:
1)PLACE OF DELIVERY___________________
2)PERSONWHO CONDUCTED DELIEVERY__________________
3)DURATION OF PRAGNANCY____________________
4)MODE OF DELEIVERY______________________
5)DURATION OF LABOUR_____________________
6)ANY DRUGS DURING LABOUR_________________
POSTNATAL HISTORY:
1)BIRTH WEIGHT
2)DID THE CHILD CRIED IMMEDIATELY ☐YES ☐NO
3)WAS THE CHILD CYANOSED ☐YES ☐NO
4)HISTORY OF POSTNATAL HISTORY ☐YES ☐NO ____________________
5)JAUNDICE, PHOTOTHERAPY ☐YES ☐NO
VACCINATION HISTORY

4. ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
NUTRITIONAL HISTORY
▢BREASTFEEDING
1)DURATION OF EXCLUSIVE BREAST FEEDING__________________________
2)HOW OFTEN DID SHE FEED____________________
3)DOES BABY SLEEP AFTER FEEDING ☐YES ☐NO
4)IS BABY GAINING WEIGHT ☐YES ☐NO
▢BOTTLE FEEDING
1)REASON FOR BOTTLE FEEDING__________________________________
2)AGE AT WHICH BOTTLE FEEDING WAS STARTED____________________
3)DILUTION TECHNIQUE_____________________
4)FREQUENCY OF FEED_____________________
5)STERILIZATION TECHNIQUE________________
6)OTHER FLUIDS____________________________
▢WEANING
1)WHEN WAS WEANING STARTED__________________
2)TYPE OF WEANING_________________
3)LIKES AND DISLIKES____________________________
4)PROBLEMS DURING WEANING___________________
5)IS THE CHILD GAINING WEIGHT ☐YES ☐NO
6)ANY FOOD ALLERGIES ☐YES ☐NO_________________
CREATED BY DR. AAMIR KHAN
FINAL YEAR MBBS
KABIR MEDICAL COLLEGE
PESHAWAR, PAKISTAN.