Ciampeds Hx

Front 1

C

Back 1

Chief complaint( reason, current hx)

Front 2

I

Back 2

Immunizations (evaluate child's exposure to communicable diseases, vacc hx)

Front 3

A

Back 3

allergies: food drugs, environment, descrip of reactions

Front 4

M

Back 4

Medications: current, last dose, amt

Front 5

P

Back 5

Past med hx: health status, prior illnesses, injuries, birth hx, health since birth, hospitalization, surgery

Front 6

E

Back 6

Events surrounding the illness or injury

Front 7

D

Back 7

Diet: diet hx, fluid intake, urine and stool output, time and quantity of last i and o

Front 8

S

Back 8

Sxs associated with the illness or injury