Pediatric History Brenda Beckett, PA-C

History Identifying Data –name/parent’s name –date of birth/age –sex/race Source (parent and/or child) –Reliability Chief Complaint –main reason for child’s visit –Who has the concern ? History of Chief Complaint

Birth History Prenatal –Maternal health, meds, drugs or alcohol use Natal –Duration of pregnancy, labor and delivery, birth weight Neonatal –Condition of baby at birth, Apgars 1 & 5 minutes, jaundice, and other issues

Past Medical History General health Illnesses/injuries Hospitalizations Surgeries Current medications

PMH, continued Allergies –Meds and reactions –Eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hypersensitivity Immunizations –Type, dates, reactions Screening Tests –Newborn screening, H/H, lead level, vision, hearing, cholesterol

Feeding History Breast feedings –frequency and duration, any difficulties Formula feedings –type, amount, frequency Solid foods –when and what Vitamins, iron, fluoride, vitamin D Older children: present diet, milk intake, vitamins, fluoride

Development Gross motor - roll over Fine motor – grasps object Personal/Social – smile Language – babble Cognitive – school grades

Habits and Personality Relationship with parents/siblings/peers Discipline problems Crying Day and night sleep patterns Toilet training/continence –Stools and urine Exercise, “screen” time, interests

Family History –Include child’s parents, grandparents, siblings Social History –Current living arrangement Who lives with child? Parents divorced –Who cares for child? daycare –Parents’ occupation/employment

Anticipatory Guidance Anticipate next step in growth / development Discuss common issues, concerns, areas for problems

Review of Systems A focused ROS is essential for any identified problem ! High incidence disease/disorder: Vision/hearing Skin Respiratory Gastrointestinal Genitourinary

HPI History of present illness –Time of onset, initial symptoms, subsequent systems Feeding difficulties –Refusal of liquids/solids Sleeping difficulties Playful/alert or acting sick Temperature taken at home Medications/dosage **What concerns parent the most?