History
People present (Introduction to child and establish carer relationship)
Identifiers (confirms wrist band)
Rapport - Name, what do you like to be called, Family, school, teacher, tv, music, sport..
You wouldn't know how to count yet;)
Question child (if school age) then parents (age appropriate toy for bored children for parental concentration)
Open: Why have you come, what do you think is wrong?
Closed:
Question without parent if school aged
HPCx
When last well?
What symptoms since?
Why prompted you come in?
What do you think is wrong?
Timing - acute/chronic,
static/progressive
For any symptoms not just pain
Site
Onset - When AND sudden or gradual AND progression
Character
Radiation
Associations
Time course ie constant v fluctuant
Exacerbating/Relieving
Severity
Pregnancy
IVF
- 3% of Australian births
Gestation
Delivery
PMHx
List of all Teams involved
Pubertal Hx
OG
Neuro
-progressive ?metabolic ?neurodegenerative
Development
Immunisation
SADAM
Alcohol
AUDIT
Psych
DASS
Development
Behaviour/interaction - feeding, toilet training, dressing
Speech, hearing/comprehension/expressive point..
Fine motor
Gross motor
Cognitive - learning, problem solving
Diet
How (W/W/W) Why
Mode breast/bottle > cup (by 1yo)
timing of introduction of solids/weaning
Amount of milk/juice/water
Who shops/cooks/dictates meal type/timing
Meals (potion ratios)
carbs wholemeal? fibre, Ca, Fe
Serves of fruit
Serves of veges
number of Snacks
Money to purchase snacks
Cost stressor
Supervised after school
Periods of starvation followed by binge
Dinner with family no TV?
Seconds?
Exercise: structured, incidental
Opportunities to increase
FHx
Genogram (confirm genetics)
Psychosocial (thinking about how there illness might interact)
Who's primary carer, discipliner, any help, daycare
Bullying, friendships (do you eat with them/see them outside school) within Kin
Do you ever say things you regret
Finances stress
Housing
DV - CPS, "sometime children / young people experience things the can be distressing, have you ever experienced anything like this.."
Disorganised
Illness
Work stress
Transition to adult care stress
Spirituality
societal / Cultural / Philosophy stress (do you feel like to need to be a person you're not/feel other should be a way they aren't)
Effect on autonomy
Illness visible to others
illness impairing function
Psychologist: may not be able to change aspects of the illness but can change the way we perceive them
HEEADSSS
Home (what do you enjoy, what stresses you)
Education/Employment (grade), Eating, Exercise
Activities with peers
Drugs, have you ever smoked cigs, OH
Sleep, Sexuality, Suicide, Spirituality, Safety (do you have some one to talk to)
Medications
over the counter
herbal
non prescribed
Corroboration with GP/Pharmacist/sticker/dosette/dc sum
Systems review - all of the above
Short opportunity to discuss anything else without parents there
Identifiers (confirms wrist band)
- Name (preferred Nickname)
- DOB
- MRN
- Sex
- Address
- GP/Gen Paed (front sheet)
Rapport - Name, what do you like to be called, Family, school, teacher, tv, music, sport..
You wouldn't know how to count yet;)
Question child (if school age) then parents (age appropriate toy for bored children for parental concentration)
Open: Why have you come, what do you think is wrong?
Closed:
Question without parent if school aged
HPCx
When last well?
What symptoms since?
Why prompted you come in?
What do you think is wrong?
Timing - acute/chronic,
static/progressive
For any symptoms not just pain
Site
Onset - When AND sudden or gradual AND progression
Character
Radiation
Associations
Time course ie constant v fluctuant
Exacerbating/Relieving
Severity
Pregnancy
IVF
- 3% of Australian births
Gestation
Delivery
PMHx
List of all Teams involved
Pubertal Hx
OG
- Pregnant/Hx
Neuro
-progressive ?metabolic ?neurodegenerative
Development
Immunisation
SADAM
Alcohol
AUDIT
Psych
DASS
Development
Behaviour/interaction - feeding, toilet training, dressing
Speech, hearing/comprehension/expressive point..
Fine motor
Gross motor
Cognitive - learning, problem solving
Diet
How (W/W/W) Why
Mode breast/bottle > cup (by 1yo)
timing of introduction of solids/weaning
Amount of milk/juice/water
Who shops/cooks/dictates meal type/timing
Meals (potion ratios)
carbs wholemeal? fibre, Ca, Fe
Serves of fruit
Serves of veges
number of Snacks
Money to purchase snacks
Cost stressor
Supervised after school
Periods of starvation followed by binge
Dinner with family no TV?
Seconds?
Exercise: structured, incidental
Opportunities to increase
FHx
Genogram (confirm genetics)
Psychosocial (thinking about how there illness might interact)
Who's primary carer, discipliner, any help, daycare
Bullying, friendships (do you eat with them/see them outside school) within Kin
Do you ever say things you regret
Finances stress
Housing
DV - CPS, "sometime children / young people experience things the can be distressing, have you ever experienced anything like this.."
Disorganised
Illness
Work stress
Transition to adult care stress
Spirituality
societal / Cultural / Philosophy stress (do you feel like to need to be a person you're not/feel other should be a way they aren't)
Effect on autonomy
Illness visible to others
illness impairing function
Psychologist: may not be able to change aspects of the illness but can change the way we perceive them
HEEADSSS
Home (what do you enjoy, what stresses you)
Education/Employment (grade), Eating, Exercise
Activities with peers
Drugs, have you ever smoked cigs, OH
Sleep, Sexuality, Suicide, Spirituality, Safety (do you have some one to talk to)
Medications
over the counter
herbal
non prescribed
Corroboration with GP/Pharmacist/sticker/dosette/dc sum
Systems review - all of the above
Short opportunity to discuss anything else without parents there