a. Identification Procedures. Begin with identification procedures.
(1) Patient history. Obtain this information from the parent or child,
depending on the age and physical condition of the child.
(a) What is the patient's general health? Good? Fair? Poor?
(b) Which childhood illnesses has the child had? Ask about measles,
mumps, whooping cough, chickenpox, smallpox, scarlet fever, acute rheumatic fever,
diphtheria, and poliomyelitis.
Has the child had any other major illnesses?
(d) Has the child been admitted to a hospital for any problem that did
not require surgery?
(e) What immunizations has the child had? Ask about polio,
diphtheria, pertussis, and tetanus toxoid, influenza, cholera, typhus, typhoid, and the
last PPO or other skin test. Ask if the patient had any unusual reactions to
(f) Has the child had any surgery? If so, ask the dates, hospital,
diagnosis, and complications of the surgery.
(g) Has the child had any broken bones or other physical trauma such
as blunt instrument trauma? (You are asking about serious injuries.)
(h) Is the child taking any medications? Ask about current or recently
taken medications. Ask about the dosage for either a home remedy or prescribed
(i) Does the child have any allergies? Ask about allergies to
medications, environmental allergens, and foods.
(j) Has the child ever had a transfusion? If so, ask about his
reactions, the date, and the number of units transfused.
Physical examination. Examine the child thoroughly from head to toe.
(a) Search for lacerations, abrasions, trauma, and evidence of internal
injury while you are performing a regular physical examination.
(b) Perform your physical examination normally. DO NOT voice your
suspicions of child abuse or confront the parents.
Note all evidence or findings in writing.