Pediatric Health History

Pediatric Health History

Chief Complaint

■ What prompted parents to bring child to hospital? ■ What is child complaining of (pain, nausea, dyspnea)?

Focused Symptom Analysis

■ P: Precipitating or palliative factors. ■ Q: Quality/quantity; describe symptom(s). Are ADLs affected? ■ R: Radiation/region/related symptoms. ■ S: Severity; is symptom mild, moderate, or severe? ■ T:Timing; time of onset, frequency, and duration.

Immunization History

■ Are child’s immunizations up to date? ■ Has child ever been diagnosed with a communicable disease? ■ Has there been any recent exposure to a communicable disease?

Allergies

■ Has child ever had allergic reaction to food, meds, etc.? ■ What types of reactions occur with known allergies?

Medications

■ Is child currently taking any medications? (Include OTC and prescription medications and herbal remedies.) ■ What was time and dose of last medication taken?

Past Medical History

■ Prior illnesses and injuries. ■ Past or recent hospitalizations and surgical procedures. ■ 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?