Identifying Data (ID)
• Name, age (years + months), sex, race
• Individuals accompanying the patient and their relationship to patient
• Previously healthy or any known major diagnoses
Chief Complaint (CC)/Reason for Referral (RFR)
• In patient’s or parent’s words (include duration of symptoms)
History of Present Illness (HPI)
• Open‐ended question, allow parents or child to express their concerns
• Select key symptoms and expand (OPQRSTUVW+ARC):
o Onset (“When was your child last well?”), frequency, duration,
timing (intermittent vs. constant),
o Progression of illness over time (“What happened next?”)
o Quality of symptoms (description, character)
o Relieving and aggravating factors
o Severity of symptoms (quantity, visual analog scale)
o Timing and treatments sought out thus far
o U – “How is this illness affecting U?” (school, work, activities
missed)
o V – Déjà Vu: “Has this happened to you before”, similar past
episodes and treatment, outcome, complications
o What do you think is going on or what are you worried about?
o Associated Symptoms (e.g., if CC is vomiting, ask about abdominal
pain, diarrhea, fever etc.)
o Risk Factors (e.g., if CC is cough, ask about personal and family
history of asthma, eczema, atopy, allergies, exposure to smoking)
o Complications (e.g., if CC is sickle cell crisis, ask about transfusions,
chest crises, ICU admissions, major infections etc.)
• For any infectious disease symptoms always ask: recent exposures to
sick contacts (family, daycare, school), recent travel, recent antibiotic
use, animal or pet exposure
• Current hospital management: What has happened so far since you
arrived at the hospital? Treatments received, investigations, your
understanding of the plan for admission
Past Medical History (PMHx)
• Significant past or ongoing medical problems including:
o Acute illnesses requiring ER visits, antibiotics, hospitalization
o Chronic illnesses (e.g. asthma, diabetes, congenital heart disease)
o Surgeries
o Accidents or injuries
o Community resources/services involved or referrals in place (e.g.
speech and language, occupational therapy)
o Other physicians or specialists involved in care
Prenatal/Pregnancy History (Preg)
• Mother’s age
• Obstetrical history – GTPAL
• Current pregnancy – “How was your pregnancy?” Any complications?”
o Screening: blood group, Rh, DAT, HBsAg, Rubella, Syphilis, HIV, GBS
o Genetic screening: MSS, FTS, IPS, amniocentesis, special tests
o Ultrasounds
o Complications: illnesses, infections, bleeding, gestational diabetes
(GDM), gestational hypertension (GHTN),
• Medications, vitamins, iron, smoking, drinking, drug use
Labour and Delivery or Birth History (L&D)
• Gestational age at birth, birth weight
• Labour complications: prolonged rupture of membranes, maternal
temperature, fetal tachycardia, meconium
• Spontaneous vaginal delivery (SVD), interventions required: forceps,
vacuum, caesarian section (C/S) and why
• Resuscitation: APGAR score, routine care, need for resuscitation, NICU
admission, duration
Newborn or Neonatal History (Neonatal)
• Common problems: jaundice, poor feeding, difficulty breathing,
cyanosis, seizures
Medications (MEDS)
• Current medications, purpose, start date, dose, duration, recent
changes and compliance
• Past medications taken for an extended period of time
• Over the counter (OTC), complementary and alternative products
(CAM), vitamins
Allergies
• Commonly no known drug allergies (NKDA)
• Medications, type of reaction (If anaphylactic then Medic alert, epipen)
• Environmental, seasonal, food
Immunizations
• Check if immunizations up to date (IUTD), any additional vaccines
given
• Ask to see immunization record
Developmental History
• Have you ever had any concerns about your child’s development? Has
there been any regression or plateau?
• How does child compare with siblings?
• Use major milestones (walking, first word, toilet training, etc) to assess
previous development
Ask about current milestones as appropriate for age:
o Gross motor
o Fine motor
o Language: receptive and expressive (verbal and non‐verbal)
o Social/Behavioural
Nutrition History
• Breast feeding: exclusively, duration, frequency
• Formula: brand, how is it prepared, # of feedings/day, quantity
• Solids: when started, tolerated, any reactions
• Present diet: cereals, fruit, veggies, protein, amount and type of milk
• Vitamins (especially iron and Vitamin D): which ones, how often, dose
• Any difficulties with feeding? Food intolerances? Allergies?
Family History (FHx)
• Draw pedigree
• Parents’ age, education level, occupation, health status
• How many siblings? Ages, names, are they healthy? Are there any
childhood diseases or genetic disorders in the family?
• Any recurrent pregnancy losses, early childhood deaths
• Consanguinity – Were mother and father related before marriage?
• General family history (1‐2 generations)
• Relevant, disease specific family history (3 generations) (i.e.
autoimmune history in Type I DM, atopic history in asthma)
Social History (SocHx)
• Who lives at home? Who are the primary caregivers? Parents work
outside the home?
• Does the child attend daycare?
• School, grade, progress, future plans
• What does your family do for fun? What does your child do for fun
(music, sports, clubs, friends, interests)?
• Stability of support network: relationship stability, frequent moves,
major events (death in family etc), financial problems, substance abuse
in home
• School adjustment, behaviour problems, habits (nail‐biting, thumb
sucking etc), sleep changes
• How has this illness/disease affected your child/ your family?
• Services involved: CCAC, nursing, occupational therapy, dietician,
physiotherapy
Review of Systems/Functional Inquiry (ROS/FI)
General: changes in feeding, sleep, weight loss, growth, energy, fevers,
signs of illness in kids: activity, appetite, attitude
HEENT: infections (how often, fever, duration), otitis, croup, nasal
discharge/congestion, sore throats, nosebleeds, swollen glands,
choking or coughing with feeding, auditory or visual changes
Cardio: infants: fatigue/sweating during feedings, cyanosis
older kids: syncope, murmurs, palpitations, exercise intolerance
Resp: cough, wheezing, dyspnea, snoring, respiratory infections
GI: appetite, weight changes, nausea, vomiting, diarrhea,
constipation, abdominal pain, distention, encopresis, toilet
training
GU: urinary: pain, frequency, urgency, incontinence, flank pain,
menarche/menses, sexual activity, STI history, discharge,
pruritis
MSK: myalgias, arthralgias, joint pains, stiffness
Neuro: headaches, tics, staring spells, head trauma, paralysis, weakness,
sensory changes
Skin: rashes, jaundice, infection, birthmarks, bruising, petechiae

Paediatric history taking ·
Begin with standard things:
patient name, presenting complaint, history of presenting complaint and past
medical history.
· Then ask BIFIDA:
Birth details and problems
Immunisations
Feeding
Infection, exposure to
Development, normality of
Allergies
· End by customary review of the rest of the standard things: medications,
family history and social history