PEDIATRIC HISTORY FORM

In 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. Thank
you!
BACKGROUND INFORMATION FOR THE CHILD
Name:

Todays Date

Birth Date:_____________ Age:_______ Sex:_______

Diagnosis:_______________________________________________________________________________
What are the present concerns for your child?_____________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________
Who are your childs doctors?_____________________________________________________________

FAMILY INFORMATION
Fathers name:_______________________________ Mothers name:_____________________________
Guardians name:____________________________ Relationship:_______________________________

CHILDS MEDICAL HISTORY

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 the
last 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

_____Apnea monitor

_____Feeding pump

_____Suction

_____Body brace

_____Hand brace
_____Foot brace
_____Stroller

_____Ventilator

EDUCATIONAL/THERAPY HISTORY
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:

_________________

_______________

MATERNAL PREGNANCY/DELIVERY/NEONATAL HISTORY (if child is less than 3

years old)
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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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?__________________________________________

DEVELOPMENTAL HISTORY (if child is less then 3 years old)

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?_____________________________________

SENSORY HISTORY
Does your child:

Always

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?

_______

_______

_______

_______

_______

_______

_______

_______

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?

_______

_______

_______

_______

8. Continually seek out movement by running, swinging,

Patient
Signature
jumping, etc?

Frequently Rarely/Never

Date

Past

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CURRENT FEEDING SKILLS

(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
____ Wheelchair
____ Highchair
____ Other:__________________________
2. Bottle/Breast Feeding
a. 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:
f. Weak or ineffective suck?
g. Was child colicky?
3. Cup Drinking
a. Type of cup drinking (please circle) Straw Spout
b. Does child drink
c. How many ounces does child drink per meal

____Feeder Seat
____ Booster Seat

_________________________________________
_________________________________________
_________________________________________
_________________________________________
____ Independently ____Help Holding Bottle
_________________________________________
_________________________________________
Regular Cup Other:_____________________
____ Independently ____ With Help
_________________________________________

4. Foods
a. 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
____ Fork
f. Length of feeding time per meal:______________________________________________________________
g. Please indicate behaviors associated with feeding:____Indicates hunger ____Refuses to eat
____ Happy to eat
____ Ready to eat
5. 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:_________________________________________________
Macintosh HD:Users:Bryan:Documents:Projects:Clients:Generation Care:From Client:New Content:Becoming a Patient - Pre-Register Pediatric Medical History Form DONE.doc

_________________________________________
Parent/Guardians signature

_____________________________
Therapist signature and date

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