PEDIATRIC HISTORY SCORING FORM

First Name:
Last Name:
Student ID:

Chief Complaint
Elicit chief complaint	select answerYesNo

Past Medical History
Planned pregnancy?	select answerYesNo
Age during pregnancy?	select answerYesNo
Who is the child's father? Does the child see him? Does he help with providing for the child?	select answerYesNo
When did you begin receiving prenatal care?	select answerYesNo
Any complications during your pregnancy?	select answerYesNo
Any harmful exposures? (EtOH? Illicit, OTC or prescription drugs? Environmental exposures?)	select answerYesNo
How many weeks long was your pregnancy? (40 weeks = full term)	select answerYesNo
Vaginal or Cesarean section delivery?	select answerYesNo
Any complications during the child's birth?	select answerYesNo
Child's birth weight and Apgar scores?	select answerYesNo
When did you and your child leave the hospital?	select answerYesNo
Issues or concerns with newborn screening test results?	select answerYesNo
Describe the child's health in general	select answerYesNo
Child's current age and weight?	select answerYesNo
When was the child last seen by a physician?	select answerYesNo
Does the child see any other doctors?	select answerYesNo
What illnesses has the child had? (When? How often? Concerns?)	select answerYesNo
Any injuries? (If yes, when? How did the injury occur? Recovery?)	select answerYesNo
Any hospitalizations? (If yes, when? For what? How long?)	select answerYesNo
Has/is the child received/receiving childhood immunizations?	select answerYesNo
Any medications?	select answerYesNo
Any allergies?	select answerYesNo

Social History
Where do you and your child live? Safe environment?	select answerYesNo
Who lives with the child?	select answerYesNo
Who is the child's primary caretaker? Receive help caring for child from family/friends?	select answerYesNo
Do any smokers live at home with the child?	select answerYesNo
What child safety precautions have you taken? (Specifically car seat; locks on cabinets; gates blocking stairs; chemicals, drugs and weapons properly locked away; smoke and CO detectors)	select answerYesNo
Home built before 1970? (Screening for lead paint exposure)	select answerYesNo
Parental employment? Financial concerns? Health care coverage for child?	select answerYesNo
Describe the child's typical day (stay at home or attend daycare?)	select answerYesNo
Is/was the child breast fed? If yes, until when?	select answerYesNo
Describe the child's diet (ask about milk (>12 months), veggies, fruits, chicken, Cheerios)	select answerYesNo
How many meals per day?	select answerYesNo
Does child have teeth? Causing discomfort? Brushing? Dentist?	select answerYesNo
Is the child peeing o.k.? How many wet diapers per day?	select answerYesNo
Is the child pooping o.k.? Regularity? Constipation? Diarrhea?	select answerYesNo
How is the child sleeping? How long at night? Napping during the day?	select answerYesNo
Do you have any concerns about your child's development?	select answerYesNo
Is the child talking? If yes, saying what? Are words intelligible?	select answerYesNo
Gross motor functions? (Depends on age'rolling over, sitting up, crawling, standing with assistance, walking, hopping, etc.)	select answerYesNo
Fine motor functions? (Depends on age'grabbing feet, grasping objects, waving, pointing, etc.)	select answerYesNo
How is the child's behavior and activity level?	select answerYesNo
How does the child get along with peers/strangers?	select answerYesNo

Family History
Do any diseases run in your family? The child's father's family? (Specifically asthma, seizures, developmental delays, diabetes, cancer, high B.P., CAD)	select answerYesNo
How is your health? Brother's and sister's health?	select answerYesNo
How is the child's father's health? Brother's and sister's health?	select answerYesNo
Are the child's grandparents alive? (Maternal and paternal) If yes, how old and describe their health. If not, how old when they died and their cause of death?	select answerYesNo
Health of child's siblings?	select answerYesNo

MIRS
Opening	select answer12345
Elicits Spectrum of Concerns	select answer12345
Negotiates Priorities and Sets Agenda	select answer12345
Eliciting the Narrative Thread or the "Patient's Story"	select answer12345
Timeline	select answer12345
Organization	select answer12345
Transitional Statements	select answer12345
Pacing of Interview	select answer12345
Types of Questions	select answer12345
Summarizing	select answer12345
Duplication	select answer12345
Lack of Jargon	select answer12345
Verification of Patient Information	select answer12345
Verbal Facilitation Skills	select answer12345
Non-Verbal Facilitation Skills	select answer12345
Empathy and Acknowledging Patient Cues	select answer12345
Support Systems	select answer12345
Encouragement of Questions	select answer12345
Closure	select answer12345