Consultation

Pediatric clinic

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CESJUJM2606026

Sex —

Age —

Phone —

Allergies —

Presenting symptoms

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Other symptoms (not in the list)

Past medical and surgical history

Chronic illnesses

Most recent hospital admission

Procedures or surgeries

Drug / medication history

Current medications

Allergies & drug sensitivities

Check before prescribing — record any known allergy or adverse drug reaction.

Any allergy or sensitivity to any medications?

Family history

Illness in the family

Personal and social history

Smoking

Alcohol

Recreational drugs

Current HIV status or history of exposure risk

Social support (e.g. family, friends, caregiver)

Occupation

Notes

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Further visit steps after examination include differential diagnosis, diagnostics, definitive diagnosis, then Treatment (medicines, disposition, and completing care).