1. Pediatric History Brenda Beckett, PA-C

2. 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

3. 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

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

5. 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

6. 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

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

8. 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

9. 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

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

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

12. 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?