Pediatric History And Physical (Blank Template)

PEDIATRIC HISTORY & PHYSICAL

MRN#

Patient Room:

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

Identifiers: NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of ***

HPI explained by patient:

Pertinent ROS:

Pertinent physical exam findings: 

ED/ICU course:

PAST MEDICAL HISTORY

Prenatal History:

Neonatal History: 

Other History:

Immunizations:

PAST SURGICAL HISTORY

ALLERGIES

MEDICATIONS PRIOR TO ADMISSION 

NUTRITION 

SUBSTANCE USE

SEXUAL HISTORY

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEMS

VITAL SIGNS

GROWTH/DEVELOPMENT

Head circumference:

Weight:

Height: 

INTAKE/OUTAKE

I/O(24hours):

Net I/O:

PHYSICAL EXAM

General:

Cardiovascular: 

Respiratory: 

Abdominal: 

Genitalia: 

Extremities:

Musculoskeletal: 

Neurological: 

Dermatological:

HEENT:

  • Head: 
  • Eyes: 
  • Ears: 
  • Nose: 
  • Oropharynx: 
  • Neck: 

LABS

IMAGING

ASSESSMENT AND PLAN

NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of *** found to have ***, concerning for ***. Patient has the following medical issues which require the associated interventions:

  1. Problem #1
    • Intervention #1
    • Intervention #2
    • Intervention #3
  2. Problem #2
    • Intervention #1
    • Intervention #2
    • Intervention #3
  3. Problem #3
    • Intervention #1
    • Intervention #2
    • Intervention #3

 

Mr. Stepwards, MSIII

DATE

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