Date of Consult: __ |. CLINICAL HISTORY A. General Data @Prs UMC => Department of Pediatrics PEDIATRIC CLINICAL HISTORY © [NAME OF PATIENT: ‘ee: Conrected Age Date of Birth: Bithplace Sex Handedness Race/Nationalty Religion Informant: Names | Relationship to pationt: Retiabilty%): | Resi 8. Chief Complaint: _C:History of Present illness: | L Symptoms {Ast ony symptoms eppcoble tothe age ofthe pint) aneuee al weight ss weight sin ‘Citeesofappette | Ci peor activ Tdeayinarowin Gra entsbon aries) CY aan Dees headache risen eifcutios | C}esing dcaies | [5 requant ais Ty toothache Blatrinese lesecrgisses | Clesrpain Grasstascnage | Cl cemateanes Cllscrmation Dlesrascrarge | lepine Bluse of braces Weak Toot mphadenopathy | [mass musle sttines |) frequentsore roat ‘Grdivaseuar spores [lerthopnes fining sols | Ceasyatigablity | CT psliations Resprstory jexugh | Eh ayspnea ‘lavestpain ‘Gartrointestnal verting Tl sbominal pie Tiveodintaaranes | Closings of wore antes Deonstination al saktit [scat oe Genitourinary asia frequency Tenet TC edame doce (Checidintoleance | CJ heat intolerance —| C] pura ips og | Chwesiness (sleep prabiens behavioral changer | C] memory lose Ejmaodchanges | hallinations nat Biowtpans Climtation of mation Hematopoietic Lhateecing bp nto /kay/2018@pPrsy MC _ Department of Pediatrics PEDIATRIC CLINICAL HISTORY aD E. Birth and Maternal History | aA SERA || esr Taran Boa oor ee | ) Pragnnat[]Wemd CJurpimmet | Uisofanesthates: Ce Clo oof Prenatal cons SATA ordre = ae none Oro Orerm CD) Normal / Vaginal CD Hospitat Cooctor Aecetecrine Efiyectmnen’ | Cin Fecanectin | Ettveceme — | Elnane Diintection /fever O diabetes CPost-torm O Forceps: OD Health center Omidwite Cothers: ‘AOG: wks | C1] Induced labor CO Home O traditional birth fae iota aimee Sate at Darran TT roaiie Phone Shaan ees TD atcohot CProhibited drugs Bw: kg cc: cm cizarete substance abuse a se eaves ek esaae famine Ca ne saa (None Ocec Reason: None | Sx of HIE (seizures, ‘Duttrasound urinalysis Hospital: ey een ie ee ee amniocentesis Oloser/oerr ‘Attending Physician: 8 (rata jculties: o ee ypor) on srawa| ete oo ees ee ome | Q Infection Clean imaging | a ie (Cee Toone Didone Dineed for oxygen ‘hydrocephalus, i F. Past Medical Hist Ginortene Tineroon | eenentator structural aporah) | | | Past linesses Ti wone TL] Tabereaioss Ly ear oratiems Limeasies El eneumonis Eltye prablems | | [Mumps GJatersies” Ey seinures Clorickenpox _Chastims Clothes: = Bast hospitalizations | [] Yes. Details | No Gperations/Surgeries | [] Yes Detail | & injuries no fies | Medications Lex: Bea | Lae —L Ee —— —o G. Family History ‘condition el Fone ~] Di sehavior problems fa0H0,000, coy | L] iahaladaition Pama earct Chatersies/atooy | E}congenita defects/ Genetic Disorders __| C}orugadkictn asthe Developmentl Disorder TE mations problems — | Clcsncer (hats, Aspergers Disorder ec _| — toepression ont, ee, | Dl istetes Tiitearng/ision impairment TP svehistne Disorder | Cieartdsease | Elintticctuatosorder se | | | Diitypertensen Eitearningecities Trotters | Da riiney disease Reading, wting. peng. math) | Tune disease Tispesch or lnainge problem | Diteberasiss (Antievation, stuterng ete) SE iael mbp/iht/kos/hay/ 2016E)DLSUMC department of Pediatries PEDIATRIC CLINICAL HISTORY ED H. Nutritional History Feeding History Duration Complementary Feeding Current Feeding Practices. | Clereastiea Start of complementary Frequency of feeding/éay Usual consistency of food: Dormia feeding mos | C) Meas Clrwrees Cltumey Blatned __| start oftable food: mos _| Cl sors iso CE) table ood “ppatie Foodintolerance: [Jo] ves_| Food preferences: | TGv0d appetite Feeding difficulties: CJNo__ Ces | | eckyecter ——_[ulivitamins (No Eves 2 | |. Immunization History Vaccine posts Remare ae ea Ciapstiiea fa pets er — f = Pv) | SW inne zi ‘Cy Peumococrat a = acta aoe 1 era [Cr measles 1 owe = coat Se 4. Developmental History 1C] Atpar with age C] with developmental concerns (See Developmental & Behavioral History) K. Personal & Social History ‘Occupation —_| Parents are: Parental status: ‘Child lives with: | | Dsicicia! Civareat Dleeth parents ~ - Chaconne Civics Carer Her Foster Separated (rather Primary Caretdker Bovereed Dothers: E ‘Order in the frie ‘/eadei tones | Ae otivedon wip [ter Acted fh OE Television video Games | a smart phone | ‘ther members of the household Flame ope. | Baation/Sccen tine per days i ‘ier pertinent information elicted: L. Environmental History Environmental drcumstances ‘Exposure to dgarerte smoke & other = pollutants a ‘Garbage (segregation, ech | Sewage disposal Water source (érinking/woshirg) smbp /nt/kos/kay/2016@ DLSUMC Department of Pediatrics PEDIATRIC CLINICAL HISTORY aD _IL PHYSICAL EXAMINATION pa I ‘General Survey: Vital signs: BP mms HR: bom RR com Temp: Antheoporetrics: | Weight: ke Height: em He cm We for age: (escore) Ht forage: (eseore) HC forage: (escore) BMI: We for Ht (oseote) = HEENT | chest & Lungs Heart | abdomen Extremities || Senitat/nectat Neuro Exam UL, ASSESSMENT IV. PLAN, Le mbp/ibt/kos/kay/2016@ DLSUMC bepartment of Pediatrics PEDIATRIC CLINICAL HISTORY V. DISPOSITION _ LI Discharged from clinic 1 Scheduled for f-up at General Pediatrics Clinic _G] Scheduled for ftp at Subspecialty clini (Sper TL] Admitted at the wards nama (J Hoc Junior iter Senior intern bp Int /kos/kay/2016 ‘Consultare/Residentincharge Ucense No.Date of Consult | CLINICAL HISTORY @prsume Department of Pediatrics ADOLESCENT CLINICAL HISTORY A. General Data - NAME OF PATIENT: fee: Careciedige OE al Date of Birth: Birthplace: Sex Handedness: 5 Race/Nationaly Religion: informants Name: . i j Residence: 5 Relationship to patient: Reliability): * | 8. Chief Complaint: C. History of Present iliness: ote | | ' i D. Review of Systems System ae Symptoms ! (pat only symptoms eppeable tothe age of the paint) \ Gener Llweightios went ain (Lites: of appetie [CT pooraaiaty Diep in rowih Stn fe Deimension hairfoss Tl acre rite Ale | ‘ead: Eyes Ears Nose headache vision dificuties | E] hearing dficuties |] frequent colds toothache al Didiziness use oretasses Cheer pan Boros aiseharge Dental caries | lacrimaton Dlesrdischorse | Clevistais Duse of braces i ask Tarot Timphederopatiy | C] mass Tnmusde stifiness | T]irequentsve throat | Greiovaeear cyanosis orthopnes Tfeming seis | (eas otigabity iiations | Respiratory cous espe chest pain | (Gastoineestinal vomiting abdominal pan [encopresis Ti toodiintcierince | Tlpassage of worms | Claares constipation Ci sundce | Genitourinary Tl arsure frequency Dl scheree Lewes [Cieiena | Endocrine (Clcnid ntoerance —[ [J heatrtcterance —[ CJ poiuria. (Cotesia (Dooivehasi ] Nervou/Sahavo Bera vwoaknest Eiscenwetone | Etmnvorian | menor ion eating problems | C] mood changes tempor outburete naitychanges_| C]hacnations myalgia {Heros Djosntsweting | Cl imping ees | | Eooatior Tlbieeding sey bret — z 7 bp fit /kos/kay/2036E. Birth and Maternal History @)PLSUM MC Department of Pediatrics ADOLESCENT CLINICAL HISTORY PRENATAL PERINATAL | [obstetric Score: Duration & Details of Labor: ‘Complications: — Titone | eenyag Se Se Baternal age Pregnancy [JWanted [] Unplanned Use of anesthetics: Oves CN | No. of Prenatal consults: POSTNATAL | | [sternal nesses: Borne Thpeafbeive: [Pee afSaven | Anansi | | Onone Clrrom Orem Cy Normal / Vaginal CO Hospital Doctor C1 bteeding/spotting TD iypertension OPre-teem Cl caesarian Section OD tyingsin etic nurse | | | Giintection /fever- Di diatetes 1 Post-term forceps CO Health Center OQ midwite | | Clowes: 406: wis | Clinducedabor Oi tiome Ci treditinal bith | shensine { Exposure to toxigens/substances: Details of Delivery/Reason if C/S: ‘Apgar Score: } Cine Caton Hem | cote! Probes ves ow: pececiee Dlegarotto Tsunctance abuse os fa pa Dlothers — {| Work-aps done ‘amiited at EU? Ever En Fabiana aera None Dcec Reason: Cinone Cisx of Mie (seizures, [uttrasound Dorinalysis Hospital: o Poor activity irntabilty, coma, | | lamneceness — Choscroert Se tiie Feeding siicties | hypotension) others: ene eis a Cyanosis Ci Congenital | jtalization’ Tinene Heari Eye/Retinal Palio abnormalities | ce Messi | emanate Cissy Diriecon Cl brain agin eae z Respiratory Preble | fhomorhope, pevsicationsy Clean Doone Tdone Deed tr oxygen hydrocephalus, | Graton | Grammar | Gieame | emer seem | t eee | F. Past Medical History Past linesses Past hospitalizations None messes mumps Chcickenpox. Byes ino Dy ubercuisis Cy eneumonia Daterges Basinms : Details Lézr probiems eve protiems D)seaures Cloters Operations Surgeries G. Family History | Fine Dives Ono Dyes — No er kidney gisease (Autism, Aspergers Disorder ete Bi tung aiscase Bituercuose L imoprincrkos/kay/2038 TSpeech or tanguage probiem (Aniculoden, stuttering, etc) Details LI wedicat tosses] JGenetc Deorder TL Fmatinat protons - Ch astra Congenital defects (Depression, onset. | ClAlergies/Atopy ‘Intellectual Disorder TL Hearing/Vision impairme | Elcaneer [Behavior problems (ADHD, 00, CD) Ey eyenstie Disorder Bi baberes Leoring ficult } Efonig/atcarot aaeiction Biiear dsoase (Reading, wing, speling, math) Bi none | TH fiypertension Ti developmental Disorder Di others 1oO DLSUMC Department of Pediatrics ADOLESCENT CLINICAL HISTORY ED H. Nutritional History Feeding History [Duration | Complementary Feeding ‘Garrent Feeding Practices TJ eressfed Beart ofcomplementary Frequency of feeding/day : Crome feeding mos | Cleats | Ciara Siotoftabtetood: —— mos_| Elsen a ‘Appetite Foodintolerance: ——C]wo Yes _| Food preferences: | Cisoodappette Feeding sieves: Clo Elves [Diet enter ‘Multivitamins: Cno Lives 1. Immunization History J. Developmental History C1 Atparwith age C1 with developmental concerns (See Developmental & Behavioral History) Doses & Remarks 1 Vaccine Primary Doses Vaccine: Friary Doses Boosters Lies | MMR at } Co kepatitis 6 = Varicella na aad DPT ‘influenza a OPv/PV oS 1 Hepatitis A (i ntoen : Typhoid Pneumococcal ‘Meningococcal i [Dl Ratawa = HV Vaccine aa [esses ier fe meee K. Menstrual/Gynecologi History iE Menses History Remarks 1 Pain Lives TINo 2 of menarche 0 = ere ane We aiesding Between pericds? | CT Yer CN | Length of eyele: days. Vaginal discharge noted? Lives TJNo = Duration; days 7 ici een naa heal a ne | | rane? ‘Dives Dive i L Psychosocial Screening History (HEADS/SF/FIRST)_ [HOME ENVIRONMENT. ‘SCREENING QUESTIONS Wah whom does te adolescent Ive? ‘Are the parents employed? Whats ther kind of neighborhood? EMPLOYMENT & EDUCATION. ‘ave there been any recent changes nthe vig situation? How are things between parents at home? ‘re there any things inthe fomily thatthe potent would keto change? ‘3 the potent curenty emplored? 15 the patent curenty in school? Favorite subeels? ow isthe patient performing academically? ver been truant/expeled from school? ‘Any problems with cassmates/teachers? Patient's fture educaton/employment gools? DETAILS / Identified Problem Areas _mbp /)nt/eos/kay/2016ADOLESCENT CLINICAL HISTORY @)PLSUM MC Department of Pediatrics ‘there any history of physi, sexual, emotional or verbal abuse? ‘How's parento| discptne being enforced? [pRUGs [sare — re fends wsing/keliog alcohol tobacco, Wick drags, eros? os the potent been offered these drugs? If yes note ony ict drag used, type, frequency, amount. How hos this affected the adolescents day actuties? Is the patient sti using these drugs? ‘Does the weent drive? Does the patent use seatbelts o lets? ‘Does the patient enter nto highvisk situations or hazardous octtes? |s the patient member ofa frateriy/sorerty/gang/ erganiation? Isthere ofitean inthe patent's home? ‘SEXUAL ACTIVITY/SEKUALITY nt hove any questo Whats the patent's sexual orenttion? ‘oes the patent have giend/boyfend? (Ask the ptient to describe 3 ‘pica dete) |sthe poten sexily active? Ifyes, age of seal debut, no. farmers se of | conzroception pregnancies opotenies, TOs? FAMILY and FRIENDS Fomily | ahysiaue? “Ask regerting family constellation, genogram,single/merrid/separated/ Avorced/blended family, femly occupations, oder in the fonvly and other ‘members othe household 's there history of addition? Whats parent attitude toward alcohol and drugs? History of ebroncaly il or mentally challenged parent? Feends: socks,” “nerds,* ‘How does ihe eolescent ee hinsel here? ow does he/she perceive his/her Height and weight, body musculature and Perception on appearance ress, jewelry, tattoos, body plercng os fashion trends o other statement) "RECREATION iat does the patie doin shor spare Une? (Sleep, exerehe organieed or | unstractured sports, recreational activities) Wht does the tient do for fur? (TV, ideo gumes, computer games, internet ‘nd chat reoms, church ar community youths group ectives) Uh whom does the patient spend spare time? What ore his/her Hobbies/interests? How much time dees he/she spend in these actives? (TV and godoet sexposurefduration of screen time per doy) i ‘SPIRITUALITY “HOPE” or “FCA” acronym; adherence, uals, occult practices, community service or involvement. HOPE - hope or security forthe future, organized religion, personal spirituality and practices, effects on medical care and end of ife issues. | FICA faith beliefs, importance and influence of felth, community support i N smkp/ht/kos/kay/2016a ADOLESCENT CLINICAL HISTORY © DLSUMC bepartment of Pediatrics [THREATS AND VIOLENCE 1 [ithe potent ever sad/tearf unmotivated hopeless? Why? | | Ss there aris history of eitharm ar harm to others? | | | Does the patient have asukde plon? Ie there a history of running away, cru to animals ue of guns, ights, lorrest, stealing, fie ceting or fights n school? a {I, PHYSICAL EXAMINATION cellar ales ee eee, eke rete tea HEH | Anthropometrics: | Weight ks Height: em Growth Chart | We. forage: (eseore) Wt forage: (eseore) We. for Ht —fescore) BM { Classification: Interpretation: Skin HEENT || chest & Lungs Heart Abdomen, Extremities | Genital feam/ | TannerStage: —PubicHair. 1H Rectal Exam Geritala = 1 oh Breast ee ee alleen: | Rectal Exam, Neuro Exam@)PESUMC Department of Pediatrics pie ADOLESCENT CLINICAL HISTORY \. DISPOSITION f TL Biscarged hom cic CY ames he wards 1 . Scheduled for ff-up at General Pediatrics Clinic G yama i Seheiled fort at Subspeciaty clini (Specify: toc Consultant/Resident-in-charge License No. Junior intern Senior intern mbp/it/eos/kay/20368