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Pediatrics Medical History

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Essentials

Patient NameOther Data – DOB, Date, MRNSite of careHistory SourceReliability

Chief Complaint (CC)

A short description of the presenting problemRemember OPQRST: Onset, Palliate/Provoke, Quality, Region/Radiation, Symptoms (associated), Temporal aspects.

History of Present Illness

Opening statement: Chief complaint in light of the patient’s clinical contextElaborate description of the chief complaintAccompanying symptomatologyAbsent pertinent symptomatologyPertinent PMHx, Family Hx, Social HxConcluding statement: How the patient got to the care site

Past Medical History

Previous hospitalizations with month/yearFrequent visits to the emergency departmentChronic illnesses not described in HPI

Past Psychiatric History

Include when positive.

Past Surgical History

Surgeries, with month/year and hospital/surgeon, if known.

Allergies

Medicine, food, environmental

Nutrition History

Infant: formula or breastfeeding, quantity & number/dayCereal and/or solid food, via spoon or bottleTable food, commercial baby food, consistency, type.Toddler: healthy foods, minimal juice, not solely cow’s milk. Unusual eating habits, pica.School-age: Three balanced meals. Fast foodAdolescence: Fast food, dieting, body image.

Current Medications

Prescription – dose the child is receiving (ml or tabs)Over-the-counter meds, herbal supplements/teas/tonicsType, dose, frequency of antipyretics (acetaminophen, ibuprofen, aspirin)Present or previous steroid use for asthma (dose&dates)

Immunizations

Check immunization card. “Up-to-date” not valid.Include flu vaccine, Mantoux (TB).

Birth History

Gestational age (premature, full-term)Birth weightMaternal prenatal problems, Type of delivery/ difficultiesProblems in the neonatal period (jaundice, NICU stay)

Developmental History

Milestone and age it occurred. May refer to Bates for comprehensive list.E.g. Social smile, sitting up, transferring objects, cruising, walking, first word, first sentence, climbing stairs, writing.List any loss of milestones.

Gynecologic History

For the girl approaching or beyond puberty: Age at menarche, regularity of menses, intensity of flow, pain.

Family History

Age and health of siblings, parents, grandparentsIllnesses that "run in the family".Early childhood deaths. Consanguinity.Illnesses pertaining to the HPI or PMHx.

Social History

Home: number of rooms, number of occupantsPresence of pets, pests, new construction, new paint, carpets, smokers in the home.Who works in the household – occupational exposuresWho is the primary caretaker during the day? At night? Day care?School: grade, performance, favorite subject, friendsLearning disabilities, behavioral problems, bullyingTravel historyEnvironmental safety: Smoke detectors? Lead risks? Guns in the home? Seatbelts? Bike helmets? Window guards?Friends: drinking, cigarettes, drugs — by self or friends?

HEADSS Assessment

Progress sensitively, in sequence:Home – household members, family interactions, supervision, living arrangements/stresses. Is it safe?Education – grade, attendance/absence, performance, failure, best/worst subjects, suspensions, special education needs, career goals, stress.Activities – exercise & other physical activity, team sports, hobbies, afterschool job, weapon carrying & fightingDrugs – cigarettes/tobacco; duration, packs per day, alcohol: parties, binges, frequency & amount; marijuana, other drugs.Sexuality – sexual feelings, intercourse: age at first intercourse, no. of partners, contraception, STD history and prevention, hetero/homosexuality; pregnancies, abortions; father of a child, non-consensual sex.Suicide/depression – feelings about oneself, history of depression/sadness, suicide ideation, sleep difficulties.