UNIVERSITY OF CEBU College of Nursing Cebu CityPEDIATRIC ASSESSMENT (1 month to 12 years) Name of Patient ________________ Date of Birth ___________ Sex ____ I. PRENATAL HISTORY ( of mother) Ma ternal Ag e ______ Obs tetr ic Sco re G _T P_ _A__L_ M___ Prenatal Check-up: ___ Regular ___ Irregular ___ None Done by: _ _ Obstetrician __ Nurse _ _ Hilot Place : ___ Hospital ___ Clinic ___ RHU ___ Home Maternal Illness : _ None _ Fever _ Rash _ _ GDM _ Asthma __ Heart Disease _ _ UTI __ TB _ Hepatitis ___ Allerg y ___ Hypermesis ___ PIH Medications (mother) II. NATAL HISTORY Da te of Birt h ______ __ Birt h Rank _____ Apgar Score Place of De li ve ry ___ Ho spital _ Home ___ Lying- in Attendant _ _ Midwife __ Hilot __ Others Gestation _ _ Full term _ _ Preterm __ Post term Mode of Delivery __ NSVD _ Forceps_ _ C/S (indication) Presenting Part __ Cephalic _ _ Face _ Breech __ Transverse Medi cati ons _ Eye Prophylaxi s _ Vi t. K ___ Hep. B III. POST-NATAL HISTORY Feeding _ _ Breastmilk _ Milk Formula _ _ Mixed Medical Problems _ None _ _ Respiratory _ Cyanosis _ _ Sepsis _ _ Seizure __ Jaundice IV. IMMUNIZATIONS __ No _ Yes at: __ Center __Private __ Both 1 st dose 2 nd dose 3 rd dose 1 st boos ter2 nd booster None BCG DTP OPVHib Hep B Pneumoccocal Rotavirus Flu Varicella AMVMMROthers: Typhoid Hep. AMeningococcal HPV
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Age semisolid started _________________ Type __________________Food preference : _________________ Allergies _______________Food dislikes : _________________
Vitamin Supplements: Type ____________ When started ____________Amount _________ Duration ____________
VI. PAST MEDICAL/SURGICAL HISTORY ___ Unremarkable ____ Remarkable
If remarkable : ______________________________________________
VIII. GROWTH & DEVELOPMENTFirst raised head _____ Rolled over _____ Sat alone _____Pulled up _____ Walked with help _____
Walked alone _____ Talked _____Urinary continence : Day _____ Night _____Control of feces _____Comparison of development with that of other siblings __________________School Grade _____ Quality of Work _________________________
IX. BEHAVIORAL HISTORY
a. Does the child manifest behavior like thumb sucking ________Masturbation ________Temper tantrums ______Negativism ________
b. Does the child have sleep disturbances ? ___ Yes ___ Noc. Phobias __________________________________________________
d. Pica (ingestion of substances other than foods) ______________________e. Abnormal Bowel habits (stool holding) ____________________________f. Bedwetting _____________________________________________
Name of Patient ___________________________________________________
I. Endocrine __ Disturbance of growth __ Excessive fluid intake __ Polyphagia __ Goiter
J. General __ Unusual weight loss __ fatigue __ Temperature sensitivity
I. CHIEF COMPLAINTS ( History of Present Illness) __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________ .