Child History Taking

Question 1

FEVER CUDDS

Answer 1

Fever.
Ear pulling.
Vomit.
Eye discharge.
Ear discharge.
Rash.

Chest symptoms.
Urinary.
Diarrhea.
Dehydration.
Seizures.

Question 2

PAM IF BIG DEALLS:

Answer 2

Past medical Hx.
Allergies.
Meds.

Illnesses (similar episodes in family contact).
FHx.

Birth history.
Immunization.
Growth and development — Prenatal, neonatal, infancy.

Day care.
Eating.
Appetite.
Last checkup. 
Look.
Sleep.

Question 3

Fever:

Answer 3

1. Does your child have fever?
2. How high is the fever?
3. Does he/she have chills?
4. Does he/she have night sweats?

Question 4

Ear pulling:

Answer 4

Does he/she seems to pull his/her ear frequently?

Question 5

Vomit:

Answer 5

1. Has he thrown up?
2. What color is the vomit?
3. Did you see any blood in it?
4. Did the vomit had food in it?
5. Does he have nausea?

Question 6

Eye discharge?

Answer 6

1. Does he have any eye discharge?

2. How is it?

Question 7

Ear discharge?

Answer 7

Does he have any ear discharge?

How is it?

Question 8

Rash:

6

Answer 8

1. Does he have any rash?
2. Where does he have it?
3. When did the rash start?
4. Where did the rash start?
5. Has the rash moved somewhere?
6. Does the rash have itching?

Question 9

Chest symptoms:

6

Answer 9

1. Does he have cough/runny nose/chest pain/short of breath/difficulty swallowing/difficulty breathing?
2. How often does he cough?
3. Does he cough up phlegm?
4. How is the phlegm?
5. Is there any blood in the phlegm?
6. Is he making an effort to breath?

Question 10

Urinary:

Answer 10

1. Has he increase or decrease the amount of urine?
2. How many diapers does he use?
3. Has been any change in the color/odor of the urine?
4. Does he have pain when he urinates?

Question 11

Diarrhea:

Answer 11

1. Does he have diarrhea?
2. How many times did he have diarrhea?
3. Have you seen blood in the diarrhea?
4. Does the diarrhea have mucus on it?
5. Does he have pain or cries during defecation?
6. Any changes in his bowel habits?

Question 12

Dehydration:

Answer 12

1. Does he have dry mouth?
2. Are his diapers wet?
3. How long since his last wet diaper?
4. When he cries can you see any tears?
5. How is his energy?

Question 13

Seizures:

Answer 13

1. Does he have any jerk movements?
2. Has he been shaking?
3. Is any leakage of urine/stool during/after the shaking?
4. How is his level of consciousness?
5. How is he after the seizure?

Question 14

Birth history:

Answer 14

1. Was the pregnancy full term?
2. Was it a vaginal delivery or a C-section?
3. Any complications?

Question 15

Immunization:

Answer 15

Is he up to date on his vaccines?

Question 16

Growth and development — Prenatal:

Answer 16

1. Did you have routine checkups during the pregnancy?
2. Any complications during the pregnancy?
3. Did you take vitamins during the pregnancy?
4. Did you smoke/drink/use drugs during the pregnancy?

Question 17

Growth and development — Neonatal:

Answer 17

1. How long did he stay in the hospital after birth?
2. Did he require O2 after birth?
3. Did he need any medication after birth?
4. Did you start feeding him after birth?

Question 18

Day care:

Answer 18

1. Does he go to day care?

2. Do you know of any other child with the symptoms?

Question 19

Eating:

Answer 19

1. How is he eating?
2. Has he ever had any problem with any foods?
3. Did you breastfeed him?
4. How long did you breastfeed him?
5. When did he start to eat solid foods?
6. Is the formula fortified with iron and vitD?

Question 20

Appetite:

Answer 20

1. How is his appetite?

2. Any change in his appetite lately?

Question 21

Last checkup:

Answer 21

1. Do you take him to the pediatrician?
2. When was the last routine checkup?
3. Was everything fine?

Question 22

Look:

Answer 22

How does the child look to you?

Question 23

Sleep:

Answer 23

How is he sleeping?

Has his sleep change lately?