pediatric history form

8/4/2019 Pediatric History Form

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Macintosh HD:Users:Bryan:Documents:Projects:Clients:Generation Care:From Client:New Content:Becoming a Patient - Pre-Register Pediatric Medical History Form -

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PEDIATRIC HISTORY FORMIn order for us to fully address all aspects of your problem, the following information is needed.Please complete the form below as completely as you can. Feel free to ask for assistance. Thayou!

Todays Date

Name: Birth Date:_____________ Age:_______ Sex:_______

Diagnosis:_______________________________________________________________________________

What are the present concerns for your child?_____________________________________________

____________________________________________________________________________________________________________

________________________________________________________________________

Who are your childs doctors?_____________________________________________________________

Fathers name:_______________________________ Mothers name:_____________________________

Guardians name:____________________________ Relationship:_______________________________

Immunization up to date? Y or N Has your child received a Flu vaccine this year? Y or N

Please indicate if your child has had any of the following illnesses/infections, also indicate the frequency in thelast 6 months:

Chicken Pox_________________ Strep Throat:_________________ Mumps:___________________

R.S.V.:______________________ Scarlet Fever:_______________ Pneumonia:________________

Tuberculosis:_______________ HIV:___________________ Ear Infections:____________________

Sinus Infections:____________ Nasal Drainage:________________ Bronchitis:_______________

Tonsillitis:__________________ Congestion:___________________ Asthma:__________________

Diabetes:__________________ Vomiting:____________________ Diarrhea:__________________

Constipation:_______________ Gastrointestinal Problems:_______________________________

Shunt Malfunction:__________________

Fevers below 100:________________________ Fevers above 100:__________________________

Has your child had a cardiac disorder (describe):________________________________________

________________________________________________________________________________________Has your child had a respiratory disorder (describe):_____________________________________

________________________________________________________________________________________

Has your child experienced seizures? Y or N Age of onset:______ Seizure type:____________


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Has your child had a head injury/concussion? Y or N When:____________________

Allergies to medications:_________________________________________________________________

Allergies to foods:_______________________________________________________________________

Allergies to environment:________________________________________________________________

Current Medications Reason Date Started Prescribed by

________________________ _______________ _______________ _____________________

________________________ _______________ _______________ _____________________

________________________ _______________ _______________ _____________________

________________________ _______________ _______________ _____________________

Surgeries (date and physician)__________________________________________________________

________________________________________________________________________________________

Major testing and dates ie: genetics, MRIs, CT Scans, Ultrasounds, Angiograph, Endoscopy, Bronchoscopy,Upper GI, Videoswallow study, pH probe:_________________________________________________________________________________________

_________________________________________________________________________________________

Hearing: Last exam_____________ Normal_____ Abnormal_____ Aides_______________________

Vision: Last exam_____________ Results_________________________________________________

Please indicate if your Child uses any of the following:

_____Wheelchair _____O2 Saturation monitor _____Hand brace

_____Apnea monitor _____Feeding pump _____Foot brace

_____Suction _____Body brace _____Stroller

_____Ventilator

Childs school:__________________________________ City:___________________ Grade:__________Type of school program: AL, EMI, EM, HI, LO, OHI, PI, C-Mentally I, S-Multiply I, TMI, VI:

_________________________________________________________________________________________

How often does your child receive therapy? In-school Other provider

Speech therapy: _________________ _______________

Occupational therapy: _________________ _______________

Physical therapy: _________________ _______________

Childs birth weight:______________ length:___________

Duration of pregnancy:_________ weeks gestation age.

Childs condition at birth: Apgar scores (if known) 1 minute_______ 5 minutes______

Please describe any pregnancy complications:____________________________________________

_________________________________________________________________________________________

Were drugs, alcohol, or tobacco used during this pregnancy?_____________________________


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Patient Signature Date

How does your childs development compare to siblings: Slower____ Faster_____ Same____

At what age was your child able to:

Hold head up alone_______ Roll over purposefully_______ Sit alone____________________

Walk assisted____________ Reach for objects___________ Turn around on stomach_____Climb stairs______________ Creep on all fours___________ Say first word_______________

Walk alone_______________ Use 2-3 word phrases_______ Pull on object to stand_______

Feed self w/ fingers______ Wash face and hands________ Feed self w/ utensils_________

Bathe self_______________ Drink from cup______________ Toilet self___________________

Dress self_______________

How does your child communicate wants and needs?_____________________________________

Does your child: Always Frequently Rarely/Never Past

1. Have difficulty calming himself/herself? ______ ______ ______ ______

2. Wake frequently at night, have difficulty falling asleep? _______ _______ _______ _______

3. Have difficulty with transitions between places,

people, activities? _______ _______ _______ _______

4. Have unpredictable emotional outbursts? _______ _______ _______ _______

5. Display hypersensitivity to touch, sound, smell, light? _______ _______ _______ _______

6. Seem awkward or clumsy with movement? _______ _______ _______ _______

7. Have frequent falls? _______ _______ _______ _______

8. Continually seek out movement by running, swinging, jumping, etc? _______ _______ _______ ___

9. Resist movement or certain positions(ie: stomach/back)? _______ _______ _______ _______

10. Have difficulty interacting with other children? _______ _______ _______ _______

11. Have difficulty/resist toothbrushing/oral care? _______ _______ _______ _______

12. Accept only a very narrow range of foods? _______ _______ _______ _______

For early birth, please indicate cause:____________________________________________________

Did child require resuscitation at birth?___________________________________________________

Describe any problems affecting your child at birth or prior to going home:_________________

_________________________________________________________________________________________

How long was your child hospitalized after birth?__________________________________________


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(Please complete for feeding evaluations only)

Is your child at expected height and weight? ____Yes ____No

Describe feeding difficulty?________________________________________________________________________________

1. Position For Feeding ____ Cradled in Arms ____ Upright in Arms ____Feeder Seat ____ Wheelchair ____ Highchair ____ Booster Seat

____ Other:__________________________

2. Bottle/Breast Feedinga. Type of bottle (straight/angeled/other) _________________________________________

b. Type of nipple (straight/X-cut/orthodontic/other) _________________________________________c. Length of feeding time _________________________________________d. Frequency of feedings _________________________________________e. Does your child hold bottle: ____ Independently ____Help Holding Bottle f. Weak or ineffective suck? _________________________________________g. Was child colicky? _________________________________________

3. Cup Drinking

a. Type of cup drinking (please circle) Straw Spout Regular Cup Other:_____________________b. Does child drink ____ Independently ____ With Help

c. How many ounces does child drink per meal _________________________________________

4. Foodsa. Type of foods: ____ Smooth Puree ____ Lumpy Texture ____ Soft Table Foods

____ Solid Table Foods ____ Crackers ____Cookies

b. List favorite foods:___________________________________________________________________________c. Foods refused:_______________________________________________________________________________d. Amount of food per meal (ounces):____________________________________________________________e. Does child feed self with: ____ Fingers ____ Spoon ____ Forkf. Length of feeding time per meal:______________________________________________________________g. Please indicate behaviors associated with feeding:____Indicates hunger ____Refuses to eat

____ Happy to eat ____ Ready to eat5. Feeding Enviroment

a. ____ Meals with family ____ Meals in quiet environment ____Other:_________________ ____ Meals at school or daycare ____ Eats in front of TV

b. Please indicate time/meal child prefers: ____ A.M. ____ Breakfast ____ Lunch ____Dinner ____ Evening

c. List usual meal and snack times:______________________________________________________________________

6. During feeding does the child experience: ____ Coughing ____ Watery eyes ____ Sleepiness ____ Gagging ____ Choking ____ Gurgly voice or breathing ____ Vomiting ____ Spitting ____ Holding food in mouth ____ Wheezing ____ Reswallows ____ Food coming out nose ____ Throws food ____ Gasping for breath ____ Stuffs mouth with food

____ Pushes food away ____ Drops in O2 Sat ____ Turns head____ Grazes (eats small amounts of food all day long)____ Reddening of eyes

NON-ORAL FEEDING (circle type) OG NG NJ GT PEG G-JT

Brand of formula: _______________________________________________Does chid gag, vomit, wretch with tube feeding:___________________Schedule of non-oral feeds:_______________________________________Other concerns:_________________________________________________


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_________________________________________ __________________________Parent/Guardians signature Therapist signature and date