history taking for paeds patient age 0-13
- Primary Caregiver
- Relationship to patient
Instead of just saying child just use their name
- When did it start? How long?
- How many times in a day do you normally change diapers for poop/do they go toilet?
- How many times now in a day that has it started?(if happened recently, account for each day)
- Is the diaper fully loaded/soaked or only partly?
- Are all poos watery or you notice some solid parts? Do you notice any blood? Any particular color change?
- Do you know what may have caused this?
- Is this the first time?
- Does the child still eat and drink well? their appetite is good?
- Is it getting better or worse?
- Is there anything you notice makes it worse?
- Have you given the child anything to help? like water, ORS or medicine?
- Water/ORS: How much was given? Did they finish the bottle/cup?
- Do they pass pee normally? How much and color*
- Vomiting? How many times and contents*
- Appetite: Are they eating well? How much water do they take?
- Are they always tired, sleeping or crying?
- Do they cry with tears?
- Does your Childs body feel more warmer than usual, like a fever? Did you measure it with a thermometer?
- Does the child maybe complain of pain?
- Do you notice their tummy getting bigger or maybe any swelling around that area?
- Coughing, rhinorrhea
- Difficulty breathing? wheezing? (severe dehydration)
- Notice them losing weight?
- Skin rashes, diaper rashes
- Ask for MCH card
- Any problems for issues during pregnancy and delivery?
- If no MCH: - Pregnancy, birth, birth weight, immunization, development (compared to siblings if any)
- At birth was the baby breastfed or bottle fed?
- How long were they fed this way?
- If breastfed, how many times in a day?
- Bottle feeding: What formula? Are the instructions being followed? Are the bottles and utensils used for prep boiled everyday? Is the water used for the milk always boiled? Is hand hygiene always practiced when mixing milk? Who normally mixes the Childs milk? Has anyone new recently prepared the Childs formula?
- Amount: How many bottles given a day? What is the volume, big bottle, small bottle, do you know how much? Did you recently change the formula milk?
- At 6 months, child should be started on complementary feeds: what food is given? Do you wash and cook the food well?
- When was food first introduced the childs diet
- Any new foods tried?
- How many times does the child eat in a day? Any snacks between meals? how much does he take?
- feeding during illness: Has the feeding pattern or amount changed now?
- Any medicine given to stop diarrhea like antibiotics? Ciprofloxin
- Any allergies
- Does anyone else at home, school, daycare, communtiy have diarrhea?
- What do the childs parents do for work?
- Do they have any siblings?
- Do they attend school or stay at home?
- Where does the child live? How is the water supply? Toilet?
- Number of rooms, where does the child sleep?
- Was the child taken to any parties or social gatherings? Any travels around the country or overseas?