1
Identification
- Name, age, sex, parents
- Source of history
2
Presenting Complaint + HPI
- Symptoms in detail
- Feeding, urine output, activity
3
Birth History
- Antenatal, natal, postnatal
- Gestation, mode of delivery, birth weight
4
Developmental History
- Milestones: gross motor, fine motor, language, social
5
Immunisation
- Up-to-date as per schedule
6
Nutrition
- Breast/formula, weaning, current diet
7
Family + Social
- Consanguinity, siblings, similar illness
- Housing, parents' education
8
Examination
- Weight, height, HC plotted
- Vitals, general, systemic
9
Summary + Plan
- Differential, investigations, management
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