Pediatric History Form

Please fill out as much of this form as you can. This gives our therapists a better understanding of who your child is and how to best work with them. Please bring any medical reports you have for our records.

Form completed by: ______Date completed:______

Child’s name: ______Date of birth: ______Age: ____

Main language used at home: ______Other languages used: ______

How were you referred to our facility? □ Dr. ______□ Other: ______

Why are you coming for an evaluation? What would you like your child to do better or more independently?

______

Medical History

□ Biological Child □ Adoption □ Foster Care ||Age of child at adoption/foster placement:____

Additional information: ______

______

Pregnancy

□Prenatal Exposure to: □ alcohol □ tobacco □ drugs □ other:______

□Breech

□Other complications: ______

______

Name of Hospital: ______Length of stay:______

□ Premature (before 37 weeks) □ Post mature (after 42 weeks) || Born at ______weeks gestational age

□ Vaginal birth □ Difficult labor □ Other:______

□ C-section || Reason:______

□ Birth weight: ______Apgar scores:______

□ Complications:______

Neonatal/Infancy

□ NICU stay Hospital:______Length of stay: ______

□ Ventilator/Breathing tube □ Difficulty feeding

□ Oxygen tube □ Physical/Occupational Therapy

□ Retinopathy of prematurity □ Speech Therapy

□ Intraventricular Hemorrhage (IVH) || Grade:____ □ Reflux/Gastroesophageal Reflux Disease

□ Periventricular Leukomalacia (PVL) □ Hearing test || Results: □ Pass □Fail

Current Medical Status

Referring Physician: ______Phone: ______

Please tell us any other doctors or specialists involved in your child’s care:

______

Please list all medical diagnoses your child has, including allergies:

______Age diagnosed: ______

Please list all medications your child takes:

______Purpose:______

Does your child wear glasses or have problems seeing? ______

Has your child had a hearing test? ______When? ______

Results: ______

Please list any additional hospitalizations since birth:

Age: ______Reason: ______Length of stay:______

Age: ______Reason: ______Length of stay:______Has your child had any special tests or procedures? (eg MRI, EEG)

Date:______Procedure: ______Findings: ______

Has your child been previously evaluated or treated by an Occupational Therapist, Physical Therapist, or Speech Language Pathologist? Please describe findings or treatments: ______

______

Development – Please write at what age your child first performed the following skills, or if they are not independent with these skills, how much help is usually given:

Sat alone: ______Toilet-trained: ______

Crawled: ______Learned to write: ______

Walked: ______Said a single word: ______

Babbled: ______Dressed Him/Herself: ______

Used a cup: ______Fed Him/Herself: ______

Does your child use any special equipment at home or at school?

□ Walker □ Wheelchair □ Special cups/spoons

□ Assistive Technology || List:______□ Other: ______

□ Infant “walker” or jumper □ Infant Swing □ Exersaucer □ Sippy Cup

Speech and Language – Please list any speech/language difficulties:

______

______Have your child’s language skills decreased? (Lost words, no longer follows directions)______

Feeding- Please list any problems with eating:

______

Has your child had a swallow study given by a speech pathologist? ______

Findings: ______

School

School: ______Grade: ______

Teacher(s): ______

Support Services:

□ Individual Family Service Plan (IFSP) □ Occupational Therapy

□ Individual Education Plan (IEP) □ Assistive Technology

□ Adaptive Physical Education □ Speech Therapy

□ Physical Therapy □ Classroom Aide

□ Other: ______

□ Involved in organized activities or sports? ______

□ Any concerns or difficulties? ______Behavior

What are your child’s favorite activities? ______

What motivates your child? ______

Does your child have any behavior problems? ______

______

Does your child have any attention problems? ______

Does your child have repetitive behaviors? (eg hand flapping, rocking, lining up toys)Please list:

______

Is your child bothered by certain sensations/feelings?

□ Noises □ Textures □ Movements □ Lights □ Smells

Please specify: ______

Does your child repeat or echo certain words or phrases? ______

Please add anything else we should know about your child:

______