Republic of the Philippines
Province of Zamboanga del Norte
Siocon District Hospital
Siocon, Zamboanga del Norte
PEDIATRIC HISTORY AND PHYSICAL EXAMINATION
Name: __________________________________ Age: ____ Sex:_______Birthday: ___/ ____/ _____
Address: ______________________________________ Informant: ___________________________
Chief Complaint: ____________________________________________________________________
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History of Present Illness: _____________________________________________________________
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Past History Past Medical History
Prenatal: ________________________________________
PNC started: ______ Where: __________ ________________________________________
Maternal Illness: ____________________ ________________________________________
Medications: _______________________
Others: ____________________________ Previous Hospitalizations:
Date Diagnosis Medication
Natal: __________ __________ _______________
Where delivered: __________________ __________ __________ _______________
Assisted by: ______________________ __________ __________ _______________
Condition at birth: _________________
____________________________ Family History:
Allergy: __________ Epilepsy: _____________
Post Natal: Blood Ds: _________ Hypertension: ________
Feeding: ___________________________ Diabetes: _________ Tuberculosis: ________
Others: ____________________________ Others: _________________________________
Immunizations (doses): Allergies
BCG ______ Measles ______ PCV ______ Foods: __________________________________
DPT ______ MMR _______ Others _____ Meds: ___________________________________
OPV ______ Hib _________ Others: __________________________________
HepB _____ Rotavirus ____
Developmental Milestones:
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Review of System: Genital, urinary:
Skin: Neuromuscular:
HEENT: Muscle/Skeletal:
Respiratory: Hematologic:
Cardiac: Others
Gastrointestinal:
PHYSICAL EXAMINATION
Temp: PR: RR: B/P: O2 sat: Wt:
General Survey: awake in respiratory distress coherent oriented
Skin: (-) pallor (-) Cyanosis (-) Rashes
HERENT: Anicteric Schlerae Palpebral Conjunctiva (-) ear and nasal discharges
(-) tenderness (-)Lymphadenopathy
Chest and Lungs: Chest Expansion Breath Sounds (-) Chest Indrawing
Heart: Dynamic Precordium Rate Rhythm Murmur
Abdomen: (-)Distension Bowel Sounds Tenderness
Extremities: Pulse Motor Sensory
Genitalia: CVA tenderness
Neurologic: Seizure Paralysis
IMPRESSION:
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Physician’s Name and Signature
