Well-child check-up

Chief Complaint

  • 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
  • Surgeries

Immunization

  • What was the last immunization that your child received?

Drugs and Allergies

Developmental history

  • Milestones
  • School performance
  • Areas of concern?

Family history

  • Pedigree
  • Who lives at home?
  • Illnesses that run in family
  • Disabilities, deaths in childhood

Social history

  • School/daycare/nursery
  • Parents’ jobs
  • Smoking
  • Pets

Review of Systems

  • Complete review of systems and physical exam

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