Communication and Physical Assessment of the Child and Family : Pediatrics Health History

  • Pediatrics Health History
    • Identifying information
      • Name
      • Address
      • Telephone
      • Birth date and place
      • Race or ethnic group
      • Sex
      • Religion
      • Date of interview
      • Informant (most likely the parent)
    • Chief complaint (CC): To establish the major specific reason for the child’s and parents’ seeking of health care
    • Present illness (PI): To obtain all details related to the chief complaint
    • Past history (PH): To elicit a profile of the child’s previous illnesses, injuries, or surgeries
      • Birth history (pregnancy, labor and delivery, perinatal history)
      • Dietary history
      • Previous illness, injuries, and operations
      • Allergies
        • Has your child ever taken any prescription or over-the-counter medications that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of this medication(s)?
        • Can you describe the reaction?
        • Was the medication taken by mouth (as a tablet or syrup), or was it an injection?
        • How soon after starting the medication did the reaction happen?
        • How long ago did this happen?
        • Did anyone tell you it was an allergic reaction, or did you decide for yourself?
        • Has your child ever taken this medication, or a similar one, again?
        • If yes, did your child experience the same problems?
        • Have you told the physicians or nurses about your child’s reaction or allergy?
      • Current medications
      • Immunizations
      • Growth and development
        • Developmental milestone:
          • Age of holding up head steadily
          • Age of sitting alone without support
          • Age of walking without assistance
          • Age of saying first words with meaning
          • Age of achieving bladder and bowel control
      • Habits
        • Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals (“security” blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes)
        • Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting
        • Unusual disposition; response to frustration
        • Use or abuse of alcohol, drugs, coffee, or tobacco
    • Review of systems (ROS): To elicit information concerning any potential health problem
Body systems
Constitutional Integument Eyes Ears/nose/mouth/throat
Neck Chest Respiratory Cardiovascular
Gastrointestinal Genitourinary Gynecologic Musculoskeletal
Neurologic Endocrine
    • Family medical history: 
      • To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child’s health, such as smoking and chemical use
    • Psychosocial history: 
      • To elicit information about the child’s self-concept
    • Sexual history: 
      • To elicit information concerning the child’s sexual concerns or activities and any pertinent data regarding adults’ sexual activity that influences the child
    • Family history: 
      • To develop an understanding of the child as an individual and as a member of a family and a community
        • Family composition
        • Home and community environment
        • Occupational and educational
        • Occupation and education of family members
        • Cultural and religious traditions
        • Family function and relationships
    • Nutritional assessment: 
      • To elicit information on the adequacy of the child’s nutritional intake and needs
        • Dietary intake
        • Clinical examination
    • Sexuality
      • 12 to 14 Years of Age
        • Have adolescent identify a supportive adult with whom to discuss sexuality issues and concerns.
        • Discuss the advantages of delaying sexual activity.
        • Discuss making responsible decisions regarding normal sexual feelings.
        • Discuss the roles of gender, peer pressure, and the media in sexual decision making.
        • Discuss contraceptive options (advantages and disadvantages).
        • Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks, and discuss condoms.
        • Discuss abuse prevention, including avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defense.
        • Have the adolescent clarify his or her values, needs, and ability to be assertive.
        • If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
        • Have a confidential interview with the adolescent (including a sexual history).
        • Discuss the evolution of sexual identity and expression.
        • Discuss breast examination or testicular examination.
      • 15 to 18 Years of Age
        • Support delaying sexual activity.
        • Discuss alternatives to intercourse.
        • Discuss “When are you ready for sex?”
        • Clarify values; encourage responsible decision making.
        • Discuss consequences of unprotected sex: Early pregnancy; STIs, including HIV infection.
        • Discuss negotiating with partners and barriers to safer sex.
        • If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
        • Emphasize that sex should be safe and pleasurable for both partners.
        • Have a confidential interview with the adolescent.
        • Discuss concerns about sexual expression and identity.
    • Family health history
      • Geographic location
        • This includes the birthplace and travel to different areas in or outside of the country
          • Identification of possible exposure to endemic diseases
        • Finding out if they come from urban or rural location, the age of the home, and whether there are significant threats such as molds or pests within the housing structure
          • Children are especially susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases such as, mosquitoes or ticks in humid or heavily wooded regions
    • Family structure
      • Family assessment is the collection of data about the composition of the family and the relationships among its members
      • The most common method of eliciting information on the family structure is to interview family members. 
      • The principal areas of concern are: 
        • Family composition
        • Home and community environment
        • Occupation
        • Education of family members, and cultural and religious traditions.
    • Psychosocial history

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