Pediatric History Taking Form

Save excellent pediatric histories directly to present and review it anytime!

Done By: Faisal Khalid Alshehri

Confidentiality warning: Do not enter real patient names, MRNs, national IDs, phone numbers, exact addresses, or hospital numbers. Use patient codes only, such as Patient A or M.A.

1. Student / Documentation Details

Your Name

Role / Level

Hospital / Clinic

Rotation

Date of History

Time of History

2. Patient Demographics

Patient Code / Initials

Avoid full names or MRN.

Age

Sex

Nationality

Residence / Region

Informant

Reliability of Informant

Source of Admission

Mode of Arrival

3. Chief Complaint

Main Complaint

Duration

Other Complaints

4. History of Present Illness

HPI Narrative

Onset

Course / Progression

Severity

Aggravating Factors

Relieving Factors

Treatment Already Given

Response to Treatment

5. System-Specific Symptom Review

Fever Details

Respiratory Symptoms

ENT Symptoms

GI Symptoms

Urinary Symptoms

Neurological Symptoms

Skin / MSK Symptoms

General Symptoms

6. Feeding, Hydration, and Growth

Feeding Type

Appetite / Intake

Fluid Intake

Urine Output

Weight

Growth Concern

Dietary History

7. Red Flags / Sick Child Screen

Activity / Consciousness

Respiratory Distress

Dehydration Signs

Danger Signs

8. Past Medical and Surgical History

Past Medical History

Past Surgical History

Previous Hospital Admissions

Trauma / Accidents

9. Birth and Neonatal History

Gestational Age

Mode of Delivery

Place of Delivery

Birth Weight

Apgar / Resuscitation

NICU Admission

Neonatal Problems

10. Antenatal and Maternal History

Maternal Pregnancy History

Maternal Medications / Exposures

Maternal Infections / Screening

Consanguinity

11. Immunization History

Vaccination Status

COVID / Influenza Vaccine if Relevant

Missing Vaccines / Notes

12. Developmental History

Gross Motor

Fine Motor / Vision

Speech and Language

Social / Adaptive

Developmental Concerns

School Performance if Applicable

13. Drug and Allergy History

Current Medications

Recent Antibiotics

Allergies

Medication Compliance

14. Family History

Similar Illness in Family

Chronic / Genetic Diseases

Deaths / Miscarriages

Sibling History

15. Social and Environmental History

Living Situation

Smoke / Vape Exposure

Pets / Animal Exposure

Travel / Sick Contacts

Water / Food Exposure

Safeguarding / Home Safety Concerns

16. Review of Systems Summary

Cardiovascular

Hematology / Oncology

Endocrine

Other Systems

17. Examination Snapshot

General Appearance

Temperature

Heart Rate

Respiratory Rate

Blood Pressure

SpO₂

Weight / Percentile

Height / Length

Head Circumference if Relevant

Focused Examination Findings

18. Clinical Impression and Plan

Problem Representation

Most Likely Diagnosis

Differential Diagnoses

Investigations Suggested / Done

Management Plan

Parent Counseling / Safety Net

Learning Points / Reflection

Saved Pediatric Histories

No histories loaded yet.