History Outline - Paediatrics

History Outline

·        General data: name, DOB, Ethnicity, where they live

·        Presenting Complaint

·        History of presenting complaint:

o  Chronological and including symptoms across all systems

o  Treatments so far

o  Contact history

o  Family history of the complaint

·        Paediatric Past Medical History:

o  Antenatal

o  Birth/perinatal: Gestation, delivery, weight, APGARS, any special care, complications 

o  Feeding (breast, formula, solids) – detailed if relevant (eg which formula, how much, which solids, how much)

o  Weight – growth history, where relevant growth and puberty in family members

o  Immunisations 

·        Milestones – including relevant milestones for the child now: Cover Gross and Fine motor, receptive and expressive language, social, play and self care skills. 

o   Past medical history

o   Social/school

·        Medications

·        Allergies

·        Family History: ages and health of parents and grandparents.  Ages, names and health of siblings

·        Social History:

o   Parent‟s occupations

o   Who cares for the child

o   Schooling/childcare, performance at school

o   Behaviour at home/school

o   Sleeping arrangements and home circumstances

o   Financial circumstances

o   Alcohol, smoking

o   Pets

o   Problems/stresses at home

·        Systems enquiry

·        General questions: fatigue, lumps, itch, fevers, bleeding tendency, family interaction