PEDIATRICS HISTORY TAKING
(MY PROTOCOL)
I. PATIENT’S PROFILE
II. PRESENTING COMPLAINTS
III. HISTORY OF PRESENT ILLNESS
IV. BIRTH HISTORY
V. FEEDING HISTORY
VI. IMMUNIZATION
VII. DEVELOPMENTAL HISTORY
VIII. PAST HISTORY
IX. PERSONAL HISTORY
X. DRUG HISTORY
XI. FAMILY HISTORY
XII. SOCIO-ECONOMIC HISTORY
I. PATIENT’S PROFILE
1) Name
2) Age (Date of Birth)
3) Sex
4) Address of parents
5) Date of admission
II. PRESENTING COMPLAINTS
(Use parents’ own words + chronological order)
III. HISTORY OF PRESENT ILLNESS
1) Enquire as to when patient was last entirely well?
2) Presenting complaints
a) Time (onset , duration , frequency , course)
b) Place (site)
c) Quality (character e.g. of pain , composition of vomitus)
d) Quantity (severity of pain , amount of vomitus)
e) Provocative / alleviative factors / variations (diurnal or seasonal)
f) Associated symptoms
g) Treatment if any
3) Systemic inquiry
a) General (weight loss , appetite)
b) CVS (shortness of breath on exertion , shortness of breath and sweaty on
feeding, cyanotic spells, squatting, fainting or syncope, cyanosis, edema, chest
pain/palpitations)
(MY PROTOCOL)
I. PATIENT’S PROFILE
II. PRESENTING COMPLAINTS
III. HISTORY OF PRESENT ILLNESS
IV. BIRTH HISTORY
V. FEEDING HISTORY
VI. IMMUNIZATION
VII. DEVELOPMENTAL HISTORY
VIII. PAST HISTORY
IX. PERSONAL HISTORY
X. DRUG HISTORY
XI. FAMILY HISTORY
XII. SOCIO-ECONOMIC HISTORY
I. PATIENT’S PROFILE
1) Name
2) Age (Date of Birth)
3) Sex
4) Address of parents
5) Date of admission
II. PRESENTING COMPLAINTS
(Use parents’ own words + chronological order)
III. HISTORY OF PRESENT ILLNESS
1) Enquire as to when patient was last entirely well?
2) Presenting complaints
a) Time (onset , duration , frequency , course)
b) Place (site)
c) Quality (character e.g. of pain , composition of vomitus)
d) Quantity (severity of pain , amount of vomitus)
e) Provocative / alleviative factors / variations (diurnal or seasonal)
f) Associated symptoms
g) Treatment if any
3) Systemic inquiry
a) General (weight loss , appetite)
b) CVS (shortness of breath on exertion , shortness of breath and sweaty on
feeding, cyanotic spells, squatting, fainting or syncope, cyanosis, edema, chest
pain/palpitations)
