Pediatric assessment sheet copy

1. .Pediatric assessment sheet
Identification data:-
Patient’s Name:
Age/Sex:
CR No:
Ward:
Bed no.
D.O.A:
Diagnosis:
Surgery:
Consultant in-charge:
Address:
Mob No
Information R/T Parents:

Age Education Occupation
Mother’s Name:
Father’s Name:

Chief complaint:-
 At the time of admission


 At the time of assessment



Informant(s):

Reliability:

2. History of present illness:






















History of past illness:-

3. Family health history:-
Type of family…………….....................No. of family member………………
Family tree……






Birth history:-
 Prenatal:



 Intranatal:




 Postnatal:

4. Immunizations:-



Nutrition and Diet:-




Developmental Milestones

 Gross motor milestones:

Age Milestones About child
3 Months Neck holding
5 Months Roll over
6 Months Sits in tripod fashion
8 Months Sitting without support
9 Months Stands with support
12 Months Stands without support
15 Months Walk alone/creeps upstairs
18 Months Runs
2 years Walk up& downstairs(2 feet/step)
3 years Rides tricycles
3 years Alternate feet going upstairs
4 years Alternate feet going downstairs

5.  Fine motor milestones:
Age Milestones About child
4 Month Bidextrous reach
6 Month Unidextrous reach, transfer objects
9 Month Immature pincer grasp
12 Month Mature pincer grasp
15 Month Tower of 2 blocks
18 Month Tower of 3 blocks
2Yrs Tower of 6 blocks
3 Yrs Tower of 9 blocks, Copies circle
4 Yrs Copies cross, bridge with blocks
5 Yrs Copies triangle, gate with blocks


 Social and adaptive milestones:
Age Milestones About child
2 months Social smile
3 months Recognize mother
6 months Stranger anxiety
9 months Waves “bye-bye
12 months Come when called
18 months Copies of talks
2 yrs Ask for food, drink, toilet,
Pulls people for toys

3 yrs Knows full name &gender
4 yrs Goes to toilet alone
5 yrs Can dress and undress

6.  Language milestones:
Age Milestones About child
1 Month Alerts to sound
3 Months Coos (musical vowel sounds)
4 Months Laugh loud
6 Months Monosyllables( ba, da,pa)
9 Months Bisyllables(mama,baba,dada)
12 Months 1-2 words with meaning
18 Months 8-10 word vocabulary
2 Yrs 2-3 word sentences
3 Yrs Ask questions
4 Yrs Says song or poem, tells stories
5Yrs Asks meaning of words


General physical examination:

 Vital signs:
Parameters Normal Range Day-1 Day-2 Day-3
Pulse
Resp.
B.P.
Temp.
Spo2 %

7. Anthropometry:

Parameters Patient’s
Value
Growth charts Range b/w
50
th
to 3
rd
percentile
Interpretation
Wt.
Ht.
HC
MAC
AC
Wt. for Ht.
BMI

 Head to toe examination:
 General appearance



 Head

 Face

 Eye


 Nose


 Ear

8.  Mouth & Pharynx

 Throat


 Neck

 Chest

 Abdomen


 Limbs



 Back



 System wise assessment:
 Neurological system

9.  Respiratory system(chest)



 Cardiovascular system



 Gastrointestinal(abdomen)system



 Musculoskeletal system





 Immunological system

10.  Integument(Skin)system




 Genitourinary system



 Gynecological system


 Endocrine system


 Lymphatic system




Signature…………………….
. Date…………………………....