Any prior trauma: fractures, lacerations.Previous hospital admissions with dates and diagnoses.Start with any conditions that still affect the patient.If the past medical history is significant to the present illness, it is briefly mentioned here.Well child: It suffices to mention that there are “no concerns.”.If the child is receiving medication, record the name of the drug, dose, frequency of administration, and response to medication.Duration and a brief description of current signs, symptoms, and treatment, if any.Depending on the condition of the child, mention the following:.
Children aged > 4 years may be encouraged by the parent/guardian or clinician to report their own concerns.The presence of a parent/guardian generally facilitates taking a child's history.In addition to the details of a general medical history, there are some notable differences to be aware of when taking a pediatric medical history, including certain patient details, the source of information, and modes of communication.