Pregnancy: scan results (dating and anomaly; if had extra scans – why?), any problems (e.g. maternal illness/alcohol/drug use)
Location, mode of delivery, gestation (term = 38-42 weeks) and birth weight (normal = 2.5-4.5kg)
Birth complications, e.g. resuscitation required, birth injury, maternal/fetal compromise, risk factors for sepsis (group B Streptococcus, maternal fever, prolonged rupture of membranes), any meconium?
Neonatal problems, e.g. jaundice, fits, fevers, bleeding, feeding problems, admissions to neonatal unit/neonatal ICU
Diet and appetite – ascertain what the child normally feeds and compare against current feeding
Breast/bottle milk (usually <12 months): type (breast, standard formula, modified formula e.g. hydrolysed, high energy etc.), volume and frequency, feeding difficulties (e.g. latching difficulties, reflux symptoms, SOB)
Weaning (usually from 6 months): starts with pureed jars, then mashed up food, then solids gradually added
Solid meals and cow’s milk (usually >12 months)
Toilet training (between 2-4 years; dry by day at 2 years; dry by night at 3-4 years)
Frequency: wet nappies? (usually ~5 soaking wet nappies per day and 3 yellow stools)
Weights: ask to see The Red Book (personal child health record) – used from birth to 5 years
Puberty if older child/adolescent (on average, starts at 11 years for girls, 12 years for boys)
School progress and attendance
Developmental screen if <5 years
Smiling by 6 weeks
Turns to sounds by 6 months
Sitting by 9 months
First words by 18 months
Walking by 18 months
Short sentences by 3 years
Normal developmental milestones
Some developmental red flags
Loss of skills
Not fixing/following objects
Low muscle tone/floppy
Can’t hold objects by 5 months
Can’t sit unsupported by 12 months
Can’t walk by 18-24 months
Persistent toe walking
No speech by 18 months
Past medical history
Previous illness, accidents, surgery
Previous hospital/emergency department visits
Immunisations: up to date? – see schedule below
Current medication (including creams etc.): include dose, route, compliance
Relevant recent medication, e.g. course of corticosteroids for asthma
Allergies: drugs, foods, others
Anything relevant to HPC
Anyone else ill?
‘Anything in the family that affects newborn babies or children?’
Family unit: parents, siblings, who lives at home – draw family tree of who’s at home
Does anyone smoke in the family (inside or outside)?
Social services involvement (child, parents or siblings) or any other safeguarding concerns
Playgroup (2-5 years), nursery school (3-4 years) or school (5-16 years) – performing well?
Other, e.g. hobbies, travel, pets
Ideas, concerns and expectations
How has the illness affected the family?
Have the symptoms kept the child from attending nursery/school?
What are the parents’/child’s concerns, beliefs, hopes etc.?
2 months: 6 in 1, rotavirus, meningitis B
3 months: 6 in 1, rotavirus, pneumococcal
4 months: 6 in 1, meningitis B
1 year: MMR, pneumococcal, meningitis B, Haemophilus influenzae type B/meningitis C
Preschool (3 years 4 months): MMR, 4 in 1 (diphtheria, polio, tetanus, pertussis)