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UNIVERSITY OF CEBUCollege of Nursing

Cebu City 

PEDIATRIC ASSESSMENT(1 month to 12 years)

Name of Patient ________________ Date of Birth ___________ Sex ____

I. PRENATAL HISTORY (of mother)Maternal Age _______ Obstetric Score G __T__P__A__L___M___Prenatal Check-up: ___ Regular ___ Irregular ___ None

Done by: ___ Obstetrician ___ Nurse ___ HilotPlace : ___ Hospital ___ Clinic ___ RHU ___ Home

Maternal Illness : ___ None ___ Fever ___ Rash___ GDM ___ Asthma ___ Heart Disease___ UTI ___ TB ___ Hepatitis___ Allergy ___ Hypermesis ___ PIH

Medications (mother) ________________________________________

II. NATAL HISTORY  Date of Birth ___________ Birth Rank ________ Apgar Score _____Place of Delivery ___ Hospital ___ Home ___ Lying-in

 Attendant ___ Midwife ___ Hilot ___ OthersGestation ___ Full term ___ Preterm ___ Post termMode of Delivery ___ NSVD ___ Forceps___ C/S (indication)Presenting Part ___ Cephalic ___ Face ___ Breech ___ Transverse

Medications ___ Eye Prophylaxis ___ Vit. K ___ Hep. B

III. POST-NATAL HISTORY Feeding ___ Breastmilk ___ Milk Formula ___ MixedMedical Problems ___ None ___ Respiratory ___ Cyanosis

___ Sepsis ___ Seizure ___ Jaundice 

IV. IMMUNIZATIONS __ No __ Yes at: __ Center __Private __ Both

1st dose 2nd dose 3rd dose 1st booster 2nd booster NoneBCGDTPOPV HibHep BPneumoccocalRotavirusFlu

 Varicella AMV MMR Others:TyphoidHep. A MeningococcalHPV 

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 V. FEEDING HISTORY  

0 – 6 months ___ Breastfeed ___ Milk Formula ___ Mixed6 – 12 months ___ Breastfeed ___ Milk Formula ___ Mixed

  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 : ______________________________________________

Date Diagnosis Intervention

Hospitalization (including operation)Date Hospital Diagnosis

 VII. FAMILY HISTORY  ___ No significant FH ___ Significant FH

  __ HPN __ Diabetes __ Asthma __ Heart Disease __ Blood Disorder __ Kidney disease __ Allergy __ Cancer __ TB __ Stroke __ Seizure __ Mental DisorderOthers : _____________________________________

 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 ___________________________________________________

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X. FAMILY HISTORY (insert the Genogram at the back of this page)

XI. REVIEW OF SYSTEMS  A. Skin :

Texture ____________ Color _____________

 ___ Eruptions ___ Hydration ___ Edema ___ Hemorrhagic manifestations ___ Scars ___ Dilated blood vessels ___ Striae ___ Wrinkling

B. Eyes : __ Have the child’s eyes ever been crossed-eyed? __ Any foreign body? __ Any infection?

C. Ears/ Nose and Throat: __ Frequent Colds __ Sore throat __ Sneezing __ Stuffy nose __ Discharges __ Post-natal drip __ Mouth breathing __ Snoring __ Otitis media __ Hearing problem

D. Teeth : Age of eruption of deciduous teeth ____ Age of eruption of permanent teeth ____

E. Cardiorespiratory: __ Dyspnea __ Chest pain __ Cough __ Sputum __ Wheeze __ Expectoration __ Cyanosis __ Edema __ Syncope __ Tachycardia

F. Gastrointestina: __ Vomiting __ Diarrhea

 __ Constipation __ Abdominal pain/discomfort __ Jaundice Type of stools ____________

G. Genitourinary: __ Enuresis __ Dysuria __ Frequency __ Polyuria __ Pyuria __ Hematuria __ Vaginal discharge __ Abnormal penis/testesCharacter of stream (urine) __________________________Bladder control __________________________

H. Neuromuscular: __ Headache __ Nervousness __ Diziness __ Tingling sensation

 __ Convulsions __ Spasm __ Ataxia __ Muscle or joint pains __ Postural Deformities __ Exercise tolerance

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) __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________ .

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11. GASTROINTESTINAL

 Abdomen:

Inspection: __ Flat __ Scaphoid __ Distended __ GlobularPercussion: __ Tympanitic __ Dull __ Fluid WavePalpation: __ Normal __ Splenomegaly __ Mass

 __ Hepatomegaly Liver edge ____________Tenderness: Location_______ __ Direct __ Indirect

Bowel Sounds: __ Normal __ Hyperactive __ Hypoactive

Rectal Exam : ___________________________________________________

Comments : _____________________________________________________

12. GENITOURINARY   __ Normal __ Mass __ Tenderness (location) ____________

Genitals: __ Normal __ Discharges __ Anomaly  MALES:

Circumcised __ Yes __ NoTanner Staging: Tanner Score: _____

FEMALES:Menses started ________ __ Not ApplicableLength of Cycle: ________ __ Regular __ Irregular

Tanner Staging: Tanner Score: _____

Name of patient: __________________________________________________ jalim’11

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