VALENZUELA MEDICAL CENTER FM-PED-019

Padrigal St., Karuhatan, Valenzuela City Rev0-06/10/16

Tel. No. 294-6711
Department of Pediatrics

PEDIATRIC DATABASE
Infancy 0-2 years old
IDENTIFYING DATA

Patients name Date of Birth Age Sex

Informants name Relation to patient
Chief complaint

History of Present Illness

Past Medical History

Allergies

Accidents

Illnesses

Preventive Care /Immunization History

Vaccine
BCG
Hepatitis B
DPT/DTaP
OPV/IPV
HIB
Pneumococcal
Rotavirus
Meningococcal
Measles
Varicella
MMR
Influenza
Hepatitis A
Typhoid
others
Maternal and Birth History

Family History

Personal and Social History

Nutritional History

Oral Health

Child Safety Practices

Developmental and Behavioral Assessment

REVIEW OF SYSTEMS
General

Skin

HEENT

Respiratory

Cardiovascular

Gastrointestinal

Genital

Musculoskeletal

Neurologic

PHYSICAL EXAMINATION
General Survey

Vital Signs

HR Pulses , strong/weak/etc.
Pain scale
Anthropometric measurements
Weight kg( Percentile)
Height cm( Percentile)
BMI ( Percentile)
Nutritional Assessment and Recommendation

Skin

Head

Neck

Eyes

Ears

Nose

Mouth and Pharynx

Thorax and Lungs

Cardiovascular

Abdomen

Genitalia

Musculoskeletal

Spine for scoliosis

Extremities
Ortolanis
Barlows

NEUROLOGICAL EXAMINATION
Mental Status

Sensory

Hearing

Vision

Cranial nerves

Reflexes
Motor

Assessment and Differential Diagnosis

Plan Of Management

Accomplished by: Verified by:

Designation: Designation:

Date and Time Date and time:

 FM-PED-019
Rev0-06/10/16

VALENZUELA MEDICAL CENTER

Padrigal St., Karuhatan, Valenzuela City
Tel. No. 294-6711

Department of Pediatrics

PEDIATRIC DATABASE
Early Childhood 3-5 years old
IDENTIFYING DATA

Patients name Date of Birth Age Sex

Informants name Relation to patient
Chief complaint

History of Present Illness

Past Medical History

Allergies

Accidents

Illnesses

Preventive Care /Immunization History

Vaccine
BCG
Hepatitis B
DPT/DTaP
OPV/IPV
HIB
Pneumococcal
Rotavirus
Meningococcal
Measles
Varciella
MMR
Influenza
Hepatitis A
Typhoid
others
Maternal and Birth History

Family History

Personal and Social History

Nutritional History

Oral Health

Child Safety Practices

Developmental and Behavioral Assessment

REVIEW OF SYSTEMS
General

Skin

HEENT

Respiratory

Cardiovascular

Gastrointestinal

Genital

Musculoskeletal

Neurologic

PHYSICAL EXAMINATION
General Survey

Vital Signs

HR Pulses , strong/weak/etc.
Pain scale
Anthropometric measurements
Weight kg( Percentile)
Height cm( Percentile)
BMI ( Percentile)

Nutritional Assessment and Recommendation

Skin

Head

Neck

Eyes

Ears

Nose

Mouth and Pharynx

Thorax and Lungs

Cardiovascular

Abdomen

Genitalia

Musculoskeletal

Spine for scoliosis

Extremities

NEUROLOGICAL EXAMINATION

Mental Status

Sensory

Hearing

Vision

Cranial nerves

Reflexes

Motor
Assessment and Differential Diagnosis

Plan Of Management

Accomplished by: Verified by:

Designation: Designation:

Date and Time Date and time:

 FM-PED-019
Rev0-06/10/16

VALENZUELA MEDICAL CENTER

Padrigal St., Karuhatan, Valenzuela City
Tel. No. 294-6711
Department of Pediatrics

PEDIATRIC DATABASE
Middle Child 6-10 years old
IDENTIFYING DATA

Patients name Date of Birth Age Sex

Informants name Relation to patient
Chief complaint

History of Present Illness

Past Medical History

Allergies

Accidents

Illnesses

Preventive Care /Immunization History

Vaccine
BCG
Hepatitis B
DPT/DTaP
OPV/IPV
HIB
Pneumococcal
Rotavirus
Meningococcal
Measles
Varciella
MMR
Influenza
Hepatitis A
Typhoid
others
Maternal and Birth History

Family History

Personal and Social History

Nutritional History

Oral Health

Child Safety Practices

Developmental and Behavioral Assessment

REVIEW OF SYSTEMS
General

Skin

HEENT

Respiratory

Cardiovascular

Gastrointestinal

Genital

Musculoskeletal

Neurologic

PHYSICAL EXAMINATION
General Survey

Vital Signs

HR Pulses , strong/weak/etc.
Pain scale
Anthropometric measurements
Weight kg( Percentile)
Height cm( Percentile)
BMI ( Percentile)

Nutritional Assessment and Recommendation

Skin

Head

Neck

Eyes

Ears

Nose

Mouth and Pharynx

Thorax and Lungs

Cardiovascular

Abdomen

Genitalia

Musculoskeletal

Spine for scoliosis

Extremities

NEUROLOGICAL EXAMINATION

Mental Status

Sensory

Hearing

Vision

Cranial nerves

Reflexes

Motor
Assessment and Differential Diagnosis

Plan Of Management

Accomplished by: Verified by:

Designation: Designation:

Date and Time Date and time:

 FM-PED-019
Rev0-06/10/16

VALENZUELA MEDICAL CENTER

Padrigal St., Karuhatan, Valenzuela City
Tel. No. 294-6711
Department of Pediatrics

PEDIATRIC DATABASE
Adolescent 11-18 years old
IDENTIFYING DATA

Patients name Date of Birth Age Sex

Informants name Relation to patient
Chief complaint

History of Present Illness

Past Medical History

Allergies

Accidents

Illnesses

Preventive Care /Immunization History

Vaccine
BCG
Hepatitis B
DPT/DTaP
OPV/IPV
HIB
Pneumococcal
Rotavirus
Meningococcal
Measles
Varciella
MMR
Influenza
Hepatitis A
Typhoid
others
Maternal and Birth History

Family History

Nutritional History
Personal and Social History

HEADSS

H-HOME

E- EDUCATION/EMPLOYMENT

A-ACTIVTIES

D-DRUGS

S- SEXUALITY

S-SPIRTUALITY

S-SUICIDE/DEPRESSION

S-SAFETY

Oral Health

Child Safety Practices

Developmental and Behavioral Assessment

REVIEW OF SYSTEMS
General

Skin

HEENT

Respiratory

Cardiovascular

Gastrointestinal

Genital

Musculoskeletal

Neurologic

PHYSICAL EXAMINATION
General Survey

Vital Signs

HR Pulses , strong/weak/etc.
Pain scale
Anthropometric measurements
Weight kg( Percentile)
Height cm( Percentile)
BMI ( Percentile)

Nutritional Assessment and Recommendation

Skin

Head

Neck

Eyes

Ears
Nose

Mouth and Pharynx

Thorax and Lungs

Cardiovascular

Abdomen

Genitalia

Musculoskeletal

Spine for scoliosis

Extremities

NEUROLOGICAL EXAMINATION

Mental Status

Sensory

Hearing

Vision

Cranial nerves

Reflexes

Motor

Assessment and Differential Diagnosis

Accomplished by: Verified by:

Designation: Designation:

Date and Time Date and time: