Pediatric Health History

Pediatric Health History

Chief Complaint:
■ What prompted the parents to bring their child to the hospital?
■ What is the child complaining of (pain, nausea, dyspnea)?

Symptom Analysis:
■ P: Precipitating or Palliative factors.
■ Q: Quality/Quantity; describe symptom(s). Are ADLs affected?
■ R: Radiation/Region/Related symptoms.
■ S: Severity; is the symptom mild, moderate, or severe?
■ T:Timing; time of onset, frequency, and duration.

Immunization History:
■ Are the child’s immunizations up to date? (see Childhood Immunization Schedule this section)
■ Has the child ever been diagnosed with a communicable disease?
■ Has there been any recent exposure to a communicable disease?

Allergies:
■ Has the child ever had an allergic reaction to food, meds, and so on?
■ What types of reactions occur with known allergies?

Medications:
■ Is the child currently taking any medications? Include both prescription and over-the-counter medications.
■ What was the time and dose of the last medication taken?

Past Medical History:
■ Prior illnesses and injuries.
■ Past or recent hospitalizations and surgeries.
■ Overall health status since birth.

Events Surrounding Illness or Injury:
■ History and onset of current illness.
■ History and mechanism of injury.

Current Intake and Output:
■ Document last oral intake.
■ Has child been drinking and eating normally?
■ Assess for malnutrition and dehydration.
■ Does urine and stool output seem normal?