This pediatric assessment sheet contains sections for collecting a child's identification data, chief complaints, medical history including birth history, immunizations, nutrition, developmental milestones, physical examination findings, anthropometric measurements, and a system-by-system assessment. It aims to comprehensively document all relevant clinical information for evaluating and treating a pediatric patient.

1. .Pediatric assessment sheet
Identificationdata:-
Patient’s Name:
Age/Sex:
CR No:
Ward:
Bed no.
D.O.A:
Diagnosis:
Surgery:
Consultant in-charge:
Address:
Mob No
Information R/T Parents:
Age Education Occupation
Mother’s Name:
Father’s Name:
Chief complaint:-
 At the time of admission
 At the time of assessment
Informant(s):
Reliability:

2. Historyof present illness:
Historyof past illness:-

3. Family health history:-
Type of family…………….....................No. of family member………………
Family tree……
Birth history:-
 Prenatal:
 Intranatal:
 Postnatal:

4. Immunizations:-
Nutritionand Diet:-
DevelopmentalMilestones
Gross motor milestones:
Age Milestones About child
3 Months Neck holding
5 Months Roll over
6 Months Sits in tripod fashion
8 Months Sitting without support
9 Months Stands with support
12 Months Stands without support
15 Months Walk alone/creeps upstairs
18 Months Runs
2 years Walk up& downstairs(2 feet/step)
3 years Rides tricycles
3 years Alternate feet going upstairs
4 years Alternate feet going downstairs

5. Fine motor milestones:
Age Milestones About child
4 Month Bidextrous reach
6 Month Unidextrous reach, transfer objects
9 Month Immature pincer grasp
12 Month Mature pincer grasp
15 Month Tower of 2 blocks
18 Month Tower of 3 blocks
2Yrs Tower of 6 blocks
3 Yrs Tower of 9 blocks, Copies circle
4 Yrs Copies cross, bridge with blocks
5 Yrs Copies triangle, gate with blocks
Social and adaptive milestones:
Age Milestones About child
2 months Social smile
3 months Recognize mother
6 months Stranger anxiety
9 months Waves “bye-bye
12 months Come when called
18 months Copies of talks
2 yrs Ask for food, drink, toilet,
Pulls people for toys
3 yrs Knows full name &gender
4 yrs Goes to toilet alone
5 yrs Can dress and undress

6. Languagemilestones:
Age Milestones About child
1 Month Alerts to sound
3 Months Coos (musical vowel sounds)
4 Months Laugh loud
6 Months Monosyllables( ba, da,pa)
9 Months Bisyllables(mama,baba,dada)
12 Months 1-2 words with meaning
18 Months 8-10 word vocabulary
2 Yrs 2-3 word sentences
3 Yrs Ask questions
4 Yrs Says song or poem, tells stories
5Yrs Asks meaning of words
General physicalexamination:
 Vital signs:
Parameters Normal Range Day-1 Day-2 Day-3
Pulse
Resp.
B.P.
Temp.
Spo2 %

7. Anthropometry:
Parameters Patient’s
Value
Growth charts Range b/w
50th
to 3rd
percentile
Interpretation
Wt.
Ht.
HC
MAC
AC
Wt. for Ht.
BMI
 Head to toe examination:
 General appearance
 Head
 Face
 Eye
 Nose
 Ear

8.  Mouth & Pharynx
 Throat
 Neck
 Chest
 Abdomen
 Limbs
 Back
 Systemwise assessment:
 Neurological system

9.  Respiratory system(chest)
 Cardiovascular system
 Gastrointestinal(abdomen)system
 Musculoskeletal system
 Immunological system

10.  Integument(Skin)system
 Genitourinary system
 Gynecological system
 Endocrine system
 Lymphatic system
Signature…………………….
. Date…………………………....