I.

DEMOGRAPHIC DATA a. b. c. d. e. f. g. h. i. Initials Address Age Birth date Birth place Gender Civil status Religion Highest educational attainment date of interview: primary informant: secondary informant: other resources:

II. III. IV. V.

HISTORY OF PRESENT ILLNESS PEDIATRIC CHILDHOOD ILLNESS HEREDO- FAMILIAL HISTORY DEVELOPMENTAL HISTORY

DEVELOPMENTAL HISTORY (Determine the exact stages based on clients age and his milestone and provide some justifications that would be most applicable to the specified developmental stage) A. J. Piagets Cognitive Development Stage Specific Task(s) Evidences of Milestone Achievement B. E. Eriksons Psychosocial Development Stage Specific Task(s) Evidences of Milestone Achievement C. S. Freuds Psychosexual Development Stage Specific Task(s) Evidences of Milestone Achievement D. J. Fowlers Spiritual Development Stage Specific Task(s) Evidences of Milestone Achievement E. L. Kholbergs Moral Development Stage Specific Task(s) Evidences of Milestone Achievement F. R. Havighursts Developmental Task Stage Specific Task(s) Evidences of Milestone Achievement

VI.

INTRODUCTION TO MMDST Computation for the exact chronological age Current age WILLIAMS METRO MANILA DEVELOPMENTAL SCREENING TEST (MMDST) PERSONAL-SOCIAL 1. TASK FOR PARTICULAR MONTH SCORE PASSED/ FAILED/ REFUSED/ NO OPPORTUNITY SCORE PASSED/ FAILED/ REFUSED/ NO OPPORTUNITY SCORE PASSED/ FAILED/ REFUSED/ NO OPPORTUNITY SCORE PASSED/ FAILED/ REFUSED/ NO OPPORTUNITY JUSTFICATION

VII.

FINE MOTOR ADAPTIVE 1. TASK FOR PARTICULAR MONTH

JUSTFICATION

LANGUAGE 1. TASK FOR PARTICULAR MONTH

JUSTFICATION

GROSS MOTOR BEHAVIOR 1. TASK FOR PARTICULAR MONTH

JUSTFICATION

VIII. IX.

GORDONS 11 FUNCTIONAL HEALTH PATTERNS NUTRITION-METABOLIC ELIMINATION ACTIVITY -EXERCISE KATZ INDEX SLEEP - REST COGNITIVE-PERCEPT ROLE-RELATIONSHIP COPING- STRESS VALUE BELIEF COMPREHENSIVE PHYSICAL EXAMINATION a. Vital signs date/time of examination: Temperature Pulse rate Respiratory rate b. Anthropometric data Height Weight Head circumference Chest circumference Abdominal circumference c. General Appearance d. Focused Assessment

X. XI.

NCP APPENDIX