Pediatric History & Physical Template
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Chief Complaint:

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

Birth History:
- Gestational Age:
- Complications:
- NICU Stay:

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:

Physical Exam:
- Vital Signs & Growth Percentiles:
- General Appearance:
- HEENT:
- Cardiovascular:
- Respiratory:
- Abdomen:
- GU:
- Extremities:
- Neuro:
- Skin:

Assessment:
- Primary Diagnosis:
- Differential:

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

Provider Signature & Credentials
Date / Time