- Do you have any concerns that you would like me to address today?
History of presenting illness
- Chronological description of problem
- Onset, Location, Duration, Severity, Character, Allev/Aggrav factors, Radiation, Symptoms associated, Precipitation factors, Frequency
- B symptoms
- Infectious symptoms: fevers/chills, nausea, vomiting, diarrhea, sick contacts
Past Medical History
- Pregnancy complications (infections, prenatal care, exposure to drugs/alcohol use/medications)
- Birth – delivery, GA, weight, apgars, complications, neonatal period (feeding, breathing)
- Illnesses, hospital admissions
- What was the last immunization that your child received?
Drugs and Allergies
- School performance
- Areas of concern?
- Who lives at home?
- Illnesses that run in family
- Disabilities, deaths in childhood
- Parents’ jobs
Review of Systems
- Complete review of systems and physical exam