Standard Components of Pediatric History Taking
The standard pediatric history must include demographic data, chief complaint, history of present illness, past medical history (including birth/perinatal history), medications, allergies, family history, developmental history, social history, and review of systems—all obtained through structured, age-appropriate communication with both the child and caregivers. 1
Creating the Right Environment
Begin by introducing yourself and explaining the visit's purpose to establish clear expectations with both child and family. 1 Create a non-threatening environment where patients feel safe sharing sensitive information. 2, 1 Maintain appropriate body language by orienting toward the patient and maintaining eye contact to demonstrate engagement. 1
For adolescents specifically, explain confidentiality parameters at the session's beginning, as confidentiality concerns may prevent them from seeking care. 1 Consider seeing adolescents alone for part of the interview to allow discussion of sensitive topics privately. 1
Chief Complaint and History of Present Illness
Start with open-ended questions about the presenting complaint, allowing the patient or family to tell their story in their own words. 1 Document the patient's exact words when recording symptoms or concerns. 1
When behavioral or interactional problems are suggested, obtain a detailed sequence of events, behaviors, and family interactions associated with the clinical problem. 1 Assess the meaning and function of the behavior in relationship to the child's family context. 1
Past Medical History
Inquire systematically about:
- Birth weight, gestational age, and pertinent prenatal/perinatal history (including maternal alcohol, drug, and tobacco use during pregnancy) 2
- Past hospitalizations and operations 2
- Recent illnesses, injuries, or emergency room visits 1
- Other eye problems, injuries, diseases, surgery, and treatments (when relevant to specialty care) 2
- General health and developmental milestones 2
Review all prescription medications, over-the-counter medications, and supplements currently used. 2, 1 Document allergies or adverse reactions to medications. 2
Family History
Family history is a critical element in pediatric medicine and represents the gateway to molecular medicine for both clinicians and patients. 3 Document serious illnesses in family members, including age of onset and age at death. 1
Assess family history of psychiatric and medical disorders that may be transmitted to children through experiential or genetic mechanisms. 2 Specifically inquire about familial ocular conditions (glaucoma, age-related macular degeneration) and systemic diseases when relevant. 2 Family history serves as a diagnostic tool, helps identify patterns of inheritance, and functions as a patient-education tool. 3
Developmental History
Obtain a systematic developmental history of each parent, including their experiences in family of origin, as most parents' adaptive and maladaptive parenting strategies have been influenced significantly by how their parents raised them. 2
For the child, evaluate:
- Fine and gross motor skills through questions about writing, drawing, sports participation, and coordination 1
- Academic performance, attention span, and ability to complete tasks for school-age children 1
- Language development and social milestones 4
A comprehensive developmental history must include detailed prenatal, perinatal, and postnatal history, as exogenous causes are often identified as risks for developmental delay. 4
Social and Family Context
Ask about family composition, including who lives in the home and any recent changes in family structure. 1 Conduct a marital/relationship history to understand how the choice of partner facilitated strengths or perpetuated weaknesses in each parent. 2
Inquire about family stressors such as:
- Financial concerns, housing stability, or family conflicts 1
- Exposure to violence, substance abuse, or mental illness in the home 1
- Cultural practices or beliefs that might impact healthcare decisions 1
- Grade level in school, learning difficulties, behavior problems, or issues with social interactions 2
Behavioral and Mental Health Screening
Screen for symptoms of anxiety, depression, or mood disorders using age-appropriate questions about feelings, worries, and emotional regulation. 1 Ask about behavior at home and school, including following rules, impulsivity, and concerning behaviors. 1
Inquire about friendships, social interactions, and difficulties with peers. 1 Screen for potential trauma exposure with direct questions like "Has anything scary or concerning happened to your child since the last visit?" 1
Use standardized screening tools such as the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire. 1
Safety Assessment
Ask about home safety measures including:
- Smoke detectors, carbon monoxide detectors, and gun safety 1
- Consistent use of appropriate car restraints (booster seats or seat belts) 1
- Helmet use during biking, skating, or other activities 1
- Environmental hazards including lead, mold, or secondhand smoke exposure 1
- Screen time habits and internet safety practices with parental monitoring 1
Review of Systems
Include pertinent review of systems, specifically history of head trauma and relevant systemic diseases. 2 This should be directed based on the chief complaint and age of the patient. 2
Communication Techniques
Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment. 1 Use motivational interviewing techniques, particularly for sensitive topics or when addressing health behavior change. 1
Employ developmentally appropriate language and approaches based on the child's age. 1 Avoid rushing through the history; allow sufficient time for the patient and family to tell their story. 1
Documentation Best Practices
Document the patient's story in sufficient detail to accurately retell it, including the patient's own words when documenting symptoms or concerns. 1 Ensure appropriate delineation of past medical and surgical problems, as patients with complex histories may be evaluated differently than those with negative past medical histories. 2
Document identity and relationship of historian, as information from both the patient and informants/care partners provides added value beyond patient self-report alone, particularly when insight is impaired. 2, 1
Critical Pitfalls to Avoid
Do not focus exclusively on biomedical aspects while ignoring psychosocial factors. 1 Avoid overreliance on templates or electronic health records at the expense of patient engagement. 1
Remember that patterns of interaction may be primarily a response to a child with biological vulnerability, not just family dysfunction. 2 The most common barrier to comprehensive family history is limited time in the typical primary care encounter, yet this information remains critically important. 5
Do not rush through the history without allowing adequate time for the family to share their concerns. 1 Failing to use structured approaches leads to missed symptoms and incomplete assessments. 6