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Pediatric/ Adolescent Case History Today s Date: Patient Name Age Date of Birth Sex Address Mother s Name Father s Name Phone (Home) (Work) Phone (other) Person to be Notified In case of Emergency:
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How to fill out pediatric adolescent case history

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How to fill out pediatric adolescent case history?

01
Begin by gathering basic demographic information such as the patient's name, age, date of birth, and contact information.
02
Include a section for the patient's medical history, including any past illnesses, surgeries, or chronic conditions they may have.
03
Ask about any known allergies or adverse reactions to medications. It is important to document this information to ensure patient safety.
04
Inquire about the family history. This may include any genetic conditions, chronic diseases, or relevant medical history of close family members.
05
Include a section for current medications that the patient is taking, including any over-the-counter medications or herbal supplements.
06
Ask about the patient's developmental milestones, such as the age at which they first sat up, crawled, or walked. This can help identify any potential developmental delays.
07
Inquire about the patient's social and emotional well-being. This may include questions about school performance, peer relationships, and any recent life stressors.
08
Include a section for immunization history, documenting all vaccines received and the dates they were administered.
09
Ask about any recent or current symptoms or concerns the patient may be experiencing, and document them in detail.
10
Finally, provide space for any additional comments or notes that may be relevant to the patient's case history.

Who needs pediatric adolescent case history?

01
Pediatricians: The primary care provider for children and adolescents will need the patient's case history to gain a comprehensive understanding of their healthcare needs.
02
Specialists: If the patient is referred to a specialist, such as a pediatric neurologist or endocrinologist, their case history will be crucial in guiding the specialist's evaluation and treatment plan.
03
Emergency Physicians: In the event of an emergency, having access to the patient's case history can greatly assist emergency healthcare providers in making accurate diagnoses and providing appropriate care.
04
School Nurses: A pediatric adolescent case history can be vital for school nurses to be aware of any chronic conditions or special medical needs of the student.
05
Parents/Guardians: Having a complete and accurate case history for their child can help parents and guardians actively participate in their child's healthcare, making informed decisions and providing necessary information to healthcare professionals.

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