Pediatric History  Physical Template

Chief Complaint:

Birth History:
- Gestational Age:
- Delivery Details:
- NICU Stay:

History of Present Illness:
- Onset/Duration:
- Associated Symptoms:
- Feeding/Sleep Changes:
- Exposure History:

Developmental History:
- Gross Motor:
- Fine Motor:
- Language:
- Social:

Immunizations:

Past Medical/Surgical History:

Medications  Allergies:

Family History:

Social History:
- Household Members:
- School/Daycare:
- Safety Environment:

Review of Systems (Focused):
- Constitutional:
- ENT:
- Respiratory:
- GI/GU:
- Neuro/Psych:
- Skin:

Physical Exam:
- Vitals  Growth Percentiles:
- General Appearance:
- HEENT:
- Cardiovascular:
- Respiratory:
- Abdomen:
- GU:
- Extremities:
- Neuro:

Diagnostics:
- Labs:
- Imaging:

Assessment:
- Primary Diagnosis:
- Differential:

Plan:
- Diagnostics/Orders:
- Medications/Vaccines:
- Education  Anticipatory Guidance:
- Follow-up:

Sign-off:
- Provider Signature  Credentials
- Date / Time