History Taking

i. Biographical data

Name: _________ Medical diagnosis _________ :

Age: _________ Occupation _________ :

Gender: _________ Admission date: _________ Via __________ :

Address: _________ Race _________ :

Religion: _________ Birth date/ place _________ :

Blood type:_________ Source of data_________ :

Parent's education: Mother_______ / Father ________

Date of interview ___________ :

ii. Chief complaint/ Reason for seeking care (cc)

)One or two major symptom + their last occurrence before admission (

______________________________________________

______________________________________________

iii. Present illness (PI)

)To obtain all details related to the chief complaint. Abbreviated as

P.Q.R.S.T.U.A(

P

Palliative/what can decrease the symptom________________________ :

Provocative/ what can increase the symptom _____________________ :

___________________________________________________________

Q

Quality/ how can you describe the symptom______________________ :

R

Region/ where has the symptom occurred on your body______________:

Radiation/ does it radiate to other parts of the body. If yes, where_____ :

S

Severity/ on a pain scale of 1-10, how much is your pain_____________ :

T

Timing

Onset/ when & how did the pain or symptom start _________________ :

__________________________________________________________

Duration/ for how long does it last______ ________________________ :

Frequency/ how many times a day does it happen__________________ :

U

)Quoted statement from the patient or parents (

Understanding/ what did you thought the symptom is indicating for:

____________________________________________________"

"_____________________________________________________

A

Associated factors/ was the symptom associated with other symptoms:

___________________________________________________________

Write present illness as a paragraph

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

iv. Past illness (ph)

A- Birth history

If patient is under 2 years, collect it :

-Pregnancy/ mother health during pregnancy, any illness (HTN, DM, hemorrhage), or any infections_________________________________ :

X-ray: ______________ nutrition _____________ :

Gestation time : _________ months

Were problems faced during past pregnancy, yes/no. What were

They________________________________________________ ?

______________________________________________________

Labor/ when did your contractions first start ________________ :

How often were your contractions coming_________________ :

Were they getting stronger_________were they regular________

Delivery: Was it vaginal or cesarean.

Child condition at birth:

Crying: yes/ noBasic problems ( with respiration..ect)______________________:

Birth injury: Yes/no. What was it ________________

Birth weight: __________kgSkin color: cyanosis ( ) jaundice ( ) fever ( ) rash( )

B- Previous illnesses, injuries, or operations

Previous illnesses_____________________________________ :

Injuries: __________________________when________________

Surgical operations/ pervious hospitalization :Cause_________________________________________________

Date__________________________________________________

Treatment_____________________________________________

C- Allergies

Does the patient have allergies from food, medication, any other agents like pets, or house hold products, what is the reaction?

_____________________________________________________

________________________________________________

D- Current medications

___________________________________________________________

___________________________________________________________

Immunizations E -

The name of the disease/vaccination___________________________ :

The number of injections______________________________________ :

___________________________________________________________

The ages when administered___________________________________ :

The dosage (was the dosage of the vaccinations lessened or did they give it to the patient fully)_________________________________________:

__________________________________________________________

Vaccination not given_____________ cause_______________

Habits F-

Hours of sleep and arising___________________________________:

Regularity of stools and urination/ how many times a day :

___________________________________________________________

G- Growth and development

Growth

• Approximate/current weight at 6 months, 1 year, 2 years, and 5 years of age:

________________________________________________________

• Approximate/current length at ages 1 and 4 years:

_________________________________________________________

Head/chest circumference:_______________________________________________________

• Dentition, including age of onset, number of teeth, and symptoms

during teething:

___________________________________________________________

Developmental milestones include:

Gross motor:

• Age of holding up head steadily: _______________________________

Can patient sit/ walk:______________________________________Age of sitting alone_____________________ walking____________

Fine motor: Can patient Hold a spoon/draw/pick up something:_______________

Smiling: ________

Language:

• Age of saying first words with meaning: _________________________

Can patient talk/understand what others say:_____________________

Sociality:

• Interactions with other children, peers, and adults:__________________

Other questions:

• Present grade in school: ______________________________________

• Scholastic performance:______________________________________

• If the child has a best friend:__________________________________

H- Family medical history (used primarily to discover any hereditary

or familial diseases in the parents and child.)

chronic illnesses in the tree family of patient parents, their immediate aunts and uncles, and their grandparents ( heart problems, hypertension, cancer, obesity, cancer, DM…etc)

Age of mother______ Father ________

Illness (HTN, DM..etc): mother_________ ____father _______________

Siblings: How many_______ age of each______________________ _________________________________illness__________________

Grandparents: Age of grandmother _______ grandfather_______

If anyone deceased name cause/ date:

___________________________________________________________

___________________________________________________________

I- Family structure:

• Family composition: _____________________________________

• Home and Community Environment: _______________________

• Monthly income: _______________________________

• Occupation and Education of Family Members:________________

______________________________________________________

______________________________________________________

G- Feeding history/ diet/ nutrition assessment (significant in child less than 2 years):

• Type of feeding: breast fed Yes/No. If yes, duration_____________ Bottle fed Yes/No. if yes, at which age_______, composition of formula______________________, amount_____________ ml, frequency/day____________

• Supplements (iron, vitamins..etc): ___________________

________________________________________________

• Current diet:______________________________________ K- Psychosocial History:

Fears: adaption/regression :

Vital sings

Normal range according to age

resultVital sings

Temperature

pulse

Respiratory rateBlood pressure O2 saturation

Lab testNormal range

Result Chemistry Normal range

ResultCBC

Na+WBCK+RBC

CL-HCTCA+HGB

BunLYMPHCRT MONOGLUNeutro

Platelet

URIANLYSIS: STOOL CLUTURES:CSF:

Nursing implication

FrequencyDose Route ActionIndication

MedicationClassification

Medication