<p> Pediatric History Form</p><p>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.</p><p>Form completed by: ______Date completed:______</p><p>Child’s name: ______Date of birth: ______Age: ____</p><p>Main language used at home: ______Other languages used: ______</p><p>How were you referred to our facility? □ Dr. ______□ Other: ______</p><p>Why are you coming for an evaluation? What would you like your child to do better or more independently?</p><p>______</p><p>______</p><p>______</p><p>Medical History</p><p>□ Biological Child □ Adoption □ Foster Care ||Age of child at adoption/foster placement:____</p><p>Additional information: ______</p><p>______</p><p>Pregnancy</p><p>□Prenatal Exposure to: □ alcohol □ tobacco □ drugs □ other:______</p><p>□Breech </p><p>□Other complications: ______</p><p>______</p><p>Birth</p><p>Name of Hospital: ______Length of stay:______</p><p>□ Premature (before 37 weeks) □ Post mature (after 42 weeks) || Born at ______weeks gestational age</p><p>□ Vaginal birth □ Difficult labor □ Other:______</p><p>□ C-section || Reason:______</p><p>□ Birth weight: ______Apgar scores:______</p><p>□ Complications:______</p><p>Neonatal/Infancy</p><p>□ NICU stay Hospital:______Length of stay: ______</p><p>□ Ventilator/Breathing tube □ Difficulty feeding</p><p>□ Oxygen tube □ Physical/Occupational Therapy</p><p>□ Retinopathy of prematurity □ Speech Therapy</p><p>□ Intraventricular Hemorrhage (IVH) || Grade:____ □ Reflux/Gastroesophageal Reflux Disease</p><p>□ Periventricular Leukomalacia (PVL) □ Hearing test || Results: □ Pass □Fail</p><p>Current Medical Status</p><p>Referring Physician: ______Phone: ______</p><p>Please tell us any other doctors or specialists involved in your child’s care:</p><p>______</p><p>______</p><p>______</p><p>Please list all medical diagnoses your child has, including allergies:</p><p>______Age diagnosed: ______</p><p>______Age diagnosed: ______</p><p>______Age diagnosed: ______</p><p>______Age diagnosed: ______</p><p>Please list all medications your child takes:</p><p>______Purpose:______</p><p>______Purpose:______</p><p>______Purpose:______</p><p>______Purpose:______</p><p>Does your child wear glasses or have problems seeing? ______</p><p>Has your child had a hearing test? ______When? ______</p><p>Results: ______</p><p>Please list any additional hospitalizations since birth:</p><p>Age: ______Reason: ______Length of stay:______</p><p>Age: ______Reason: ______Length of stay:______</p><p>Age: ______Reason: ______Length of stay:______Has your child had any special tests or procedures? (eg MRI, EEG)</p><p>Date:______Procedure: ______Findings: ______</p><p>Date:______Procedure: ______Findings: ______</p><p>Date:______Procedure: ______Findings: ______</p><p>Has your child been previously evaluated or treated by an Occupational Therapist, Physical Therapist, or Speech Language Pathologist? Please describe findings or treatments: ______</p><p>______</p><p>______</p><p>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:</p><p>Sat alone: ______Toilet-trained: ______</p><p>Crawled: ______Learned to write: ______</p><p>Walked: ______Said a single word: ______</p><p>Babbled: ______Dressed Him/Herself: ______</p><p>Used a cup: ______Fed Him/Herself: ______</p><p>Does your child use any special equipment at home or at school?</p><p>□ Walker □ Wheelchair □ Special cups/spoons</p><p>□ Assistive Technology || List:______□ Other: ______</p><p>□ Infant “walker” or jumper □ Infant Swing □ Exersaucer □ Sippy Cup</p><p>Speech and Language – Please list any speech/language difficulties:</p><p>______</p><p>______</p><p>______Have your child’s language skills decreased? (Lost words, no longer follows directions)______</p><p>Feeding- Please list any problems with eating:</p><p>______</p><p>______</p><p>______</p><p>Has your child had a swallow study given by a speech pathologist? ______</p><p>Findings: ______</p><p>School</p><p>School: ______Grade: ______</p><p>Teacher(s): ______</p><p>Support Services:</p><p>□ Individual Family Service Plan (IFSP) □ Occupational Therapy</p><p>□ Individual Education Plan (IEP) □ Assistive Technology</p><p>□ Adaptive Physical Education □ Speech Therapy</p><p>□ Physical Therapy □ Classroom Aide</p><p>□ Other: ______</p><p>□ Involved in organized activities or sports? ______</p><p>□ Any concerns or difficulties? ______Behavior</p><p>What are your child’s favorite activities? ______</p><p>What motivates your child? ______</p><p>Does your child have any behavior problems? ______</p><p>______</p><p>Does your child have any attention problems? ______</p><p>Does your child have repetitive behaviors? (eg hand flapping, rocking, lining up toys)Please list:</p><p>______</p><p>Is your child bothered by certain sensations/feelings?</p><p>□ Noises □ Textures □ Movements □ Lights □ Smells</p><p>Please specify: ______</p><p>Does your child repeat or echo certain words or phrases? ______</p><p>Please add anything else we should know about your child:</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p>