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Kids Kount Version 2/2016 Confidential Personal History PEDIATRIC/ADOLESCENT INFORMATION Please print all information – failure to complete any section of this history form may result in a delay of treatment. Circle one: Daphne Mobile or School Therapy (write in school name) ___________________________ Today’s Date ________________ Client’s Full Name: _________________________________________ Preferred Name: ________________________________ Date of birth: __________________ Gender of patient Male or Female Current weight ______________ Current height _______________ Parent/Guardian’s Name: A. _____________________________________ cell phone ( )____________ B. ______________________________________ cell phone( )____________ Address: ___________________________________________________________ ___________________________________________________________ Home phone: ____________________ Email address: ______________________________________________________ Referred by: _______________________________________________________ Primary Physician: ___________________________________________________ Physician’s phone number: ____________________________________________ Primary Concern for your child: ________________________________________ Age first noted concern: __________________ School Attending: ____________________________________________________ Grade level: _______________ Insurance InformationInsurance Company ____________________________ Policy Number ____________________________ Group Number _______________________ Effective Date of Insurance __________________ Policy Holder’s Full Name _______________________________ Policy Holder DOB _______________ Policy Holder’s Employer _______________________ Policy Holder’s SS# ___________________________ Responsible Financial Party/Guarantor Information **(MUST BE COMPLETED)** Responsible Party’s Full Name _______________________________ Male or Female DOB _______________ Responsible Party’s Employer _______________________ Responsible Party’s SS# ___________________________ Signature:_________________________________________________ ChildcareIf primary caregivers work outside the home, please provide the following: Who cares for this child when caregivers are gone? _______________________________________________ How many hours per day is this child in a child-care setting? _______________________________________ How many people care for this child? _____________________ Other primary caregiver’s name? ______________________________________________________________ Social HistoryWhat language is spoken in the home? __________________________________ 1 Kids Kount Confidential Personal History Please list family members who live in the home with child: Age Sex Adopted Education/Occupation Father _____________________ ____ ____ Yes No ___________________ Mother _____________________ ____ ____ Yes No ___________________ Children ____________________ ____ ____ Yes No ___________________ ____________________ ____ ____ Yes No ___________________ ____________________ ____ ____ Yes No ___________________ Marital Status of parents: Married _____ Separated ______ Divorced ______ Other ______ Handedness R L R L R L R L R L What are your concerns for your child? Academic: __________________________________________________________________________________________ __________________________________________________________________________________________ Personal: __________________________________________________________________________________________ __________________________________________________________________________________________ Social: __________________________________________________________________________________________ __________________________________________________________________________________________ What do you consider your child’s strengths? _________________________________________________________________________________________ When you are stressed, whom do you go to for support? ____________________________________________ How many hours each day does this child spend watching TV or playing video/computer games? _________________________________________________________________________________________ Has there been any recent change or stress factors at home (i.e. job loss, divorce, death of family member, move, etc.) _______________________________________________________________________________ Labor and Delivery Describe your experience during labor and delivery: __________________________________________________________________________________________ __________________________________________________________________________________________ More specifically: Yes No Comments Full Term? ____ _____ ________________________________________________ Length of labor? ____ hrs ________________________________________________ Forceps used? ____ _____ ________________________________________________ High forceps required? ____ _____ ________________________________________________ Delivery position? (breech?) ____ _____ ________________________________________________ Caesarean birth? (reason) ____ _____ ________________________________________________ Birth weight? ____lbs ____oz APGAR rating? ___________ ________________________________________________ Cried immediately? ____ _____ ________________________________________________ Was oxygen required? ____ _____ ________________________________________________ Ventilator required? ____ _____ ________________________________________________ Phototherapy for jaundice? ____ _____ ________________________________________________ 2 Kids Kount Version 2/2016 -Did the newborn have immediate physical contact with the mother? -Was there a positive bonding experience between the mother and new born at birth? -Was the new born breastfed? Yes No -Describe any separations from the mother during the first few days of life. -Did mother experience any post-partum depression? Confidential Personal History ________________________________________________ ________________________________________________ If yes, how long? _________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Health History How far along was the pregnancy when medical care started? _______________________________________ At child’s birth, what was the mother’s age? ________________ Number of previous pregnancies? _________ Number of previous miscarriages? _______________ Length of pregnancy ______ weeks Multiple births? Yes or No If yes, #_____ of ______ Gestational age? _______ weeks Where was this child born? _______________________________________ How long was mother in the hospital? _________ days How long was the child in the hospital? _________ days Did any of the following complications occur during pregnancy? Please describe. Yes No Comments Difficulty in conception ____ ____ _____________________________________________________ Use of fertility drugs ____ ____ _____________________________________________________ In-vitro fertilization ____ ____ _____________________________________________________ Diabetes ____ ____ _____________________________________________________ Pre-eclampsia ____ ____ _____________________________________________________ Cigarette smoking ____ ____ _____________________________________________________ Stress ____ ____ _____________________________________________________ Emotional problems ____ ____ _____________________________________________________ High blood pressure ____ ____ _____________________________________________________ Alcohol use ____ ____ _____________________________________________________ Drug use ____ ____ _____________________________________________________ Bleeding ____ ____ _____________________________________________________ Infections ____ ____ _____________________________________________________ Other complications ____ ____ _____________________________________________________ Medication used during pregnancy if any: _____________________________________________________ Childhood health history Has the child had any of the following since going home after delivery? Yes No Comments Hospitalizations? ____ ____ _____________________________________________________ Surgeries? ____ ____ _____________________________________________________ Chronic illness? ____ ____ _____________________________________________________ Emergency room visits? ____ ____ _____________________________________________________ Serious accidents? ____ ____ _____________________________________________________ 3 Kids Kount Confidential Personal History Yes No Comments Current on vaccines? ____ ____ _____________________________________________________ Flu vaccine this year? ____ ____ _____________________________________________________ Synagis for RSV prevention? ____ ____ _____________________________________________________ Allergies? (food or meds) ____ ____ _____________________________________________________ Describe any present medical or health problems/conditions: __________________________________________________________________________________________ __________________________________________________________________________________________ Auditory Development Has your child experienced any problems with his/her hearing? (operations, infections, tubes) __________________________________________________________________________________________ __________________________________________________________________________________________ Ear infections? Seldom ____ sometimes ____ often ____ / mild ____ moderate ____ severe ____ Are there any current hearing problems of which you are aware? __________________________________________________________________________________________ __________________________________________________________________________________________ When/where was the last time your child had a hearing test or screening? __________________________________________________________________________________________ Childhood diet history Yes No Comments -Does your child have a limited food diet? ___ ___ _____________________________ -Does your child have a special, prescribed diet? ___ ___ _____________________________ Please describe any food preferences or aversions. __________________________________________________________________________________________ __________________________________________________________________________________________ Please indicate any of the following physicians or therapists your child has seen. Yes No Comments Audiologist/hearing test ____ ____ ____________________________________________________ Eye Doctor ____ ____ _____________________________________________________ Geneticist ____ ____ _____________________________________________________ Neurologist/neurosurgeon ____ ____ _____________________________________________________ Cardiologist ____ ____ _____________________________________________________ Gastroenterologist ____ ____ _____________________________________________________ Orthopedic/surgeon ____ ____ _____________________________________________________ Endocrinologist ____ ____ _____________________________________________________ Feeding team ____ ____ _____________________________________________________ Children’s Rehab Serv. ____ ____ _____________________________________________________ Early Intervention Serv. ____ ____ _____________________________________________________ Physical Therapist ____ ____ _____________________________________________________ Occupational Therapist ____ ____ _____________________________________________________ Speech Therapist ____ ____ _____________________________________________________ Developmental History Holds head without support Sit up without support Crawled Stand without support Age ________ ________ ________ ________ Comments _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ 4 Kids Kount Version 2/2016 Confidential Personal History Walk alone Self-fed Bladder control Bowel control Color inside lines Use scissors Dresses without help Ties shoe laces Age ________ ________ ________ ________ ________ ________ ________ ________ Comments _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Speech and Hearing Use meaningful words Name people/objects Combine words Use short sentences ________ ________ ________ ________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ -Did your child’s speech or language progression ever stop for a period of time? _____________If yes, please describe.__________________________________________________________________________________ -At what age did your child show preference for handedness? R L Mixed______________________________ -Has your child ever regressed or gone backward in his/her development? __________________________________________________________________________________________ -Why and who was this first to notice it? __________________________________________________________________________________________ -Describe any other developmental issues. __________________________________________________________________________________________ -Do people have trouble understanding your child? ________________________________________________ -Does your child ever have difficulty chewing or swallowing? ___________If yes, please describe___________________________________________________________________________________ Academic/school History At what age did your child start in structured school environment?__________________________________ How many days per week attending ___________ Hours per day _______________ Is your child teased or bullied about a speech or developmental problem? ________________________________________________________________________________ Were any grades repeated? ____yes ____no If yes, which ones and why? _________________________________________________________________________________________ How does your child get along with others at school? ______________________________________________ How does teacher or peers describe your child? ________________________________________________ What are some interests or hobbies of child? _____________________________________________________ What are some things that your child fears? ______________________________________________________ Please list any extracurricular activities that your child participates in. (sports, music, art etc.) __________________________________________________________________________________________ __________________________________________________________________________________________ Have you or has his teacher ever observed any unusual or harmful behaviors that warrant consideration? Is so, please describe. __________________________________________________________________________________________ __________________________________________________________________________________________ 5 Kids Kount Confidential Personal History Have you or has teacher noticed difficulty in reading, sounding out words or phonics (learning letters and sounds they make)? Yes No If yes, please describe. _________________________________________________________________________________________ Please indicate any items that have applied to your child: Yes No SOCIAL -Is your child affectionate ____ ____ -Does your child make eye contact ____ ____ -Does your child prefer to play alone? ____ ____ -Does your child smile to greet you? ____ ____ -Does your child notice if you are upset or cry? ____ ____ -Does your child offer to comfort you? ____ ____ -Does your child ever show you things that interest him/her? ____ ____ BEHAVIORAL -Does your child ever have compulsions or rituals? ____ ____ -Does your child respond when you call his name? ____ ____ -Does your child have excessive trouble with change? ____ ____ -Does your child demonstrate pretend play? ____ ____ -Does your child like to line up toys? ____ ____ -Will your child watch the same video all day long if allowed? ____ ____ -Is your child pre-occupied with anything? ____ ____ -Does your child have any ‘unusual’ interests or behaviors? ____ ____ Comments ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ SENSORY Yes No Comments -Does your child bite or hit himself? ____ ____ ___________________________________ -Is your child overly sensitive to noise? ____ ____ ___________________________________ -Does your child like to spin repetitively? ____ ____ ___________________________________ -Does your child have a high pain threshold? ____ ____ ___________________________________ -Do tags in shirts or socks bother your child? ____ ____ ___________________________________ -Does your child hit, bite or scratch others? ____ ____ ___________________________________ -Does your child avoid foods with certain textures? ____ ____ ___________________________________ -Does your child demonstrate rocking, head banging or hand flapping? ____ ____ ___________________________________ -Does your child smell, taste or feel things more often than others? ____ ____ ___________________________________ -Does your child tolerate structured environments or activities? ____ ____ ___________________________________ -Does your child have frequent or prolonged tantrums? ____ ____ ___________________________________ If yes, how long do they last? ___________________________________ 6 Kids Kount Version 2/2016 Confidential Personal History Please indicate if your child has any of the following: Neurological/Behavioral Respiratory Seizures Y___ N ___ Frequent ear infections Bites nails Y___ N ___ Frequent colds Sucks thumb Y___ N ___ Chronic cough Grinds teeth Y___ N ___ Asthma, hay fever Has tics or twitches Y___ N ___ Sleep Cardiovascular Snores frequently Y___ N ___ A heart problem Gasps while sleeping Y___ N ___ Heart murmur Stops breathing Y___ N ___ Gastrointestinal Trouble at bedtime Y___ N ___ Excessive vomiting Frequently wakes up Y___ N ___ Stomach pains Hard to wake up Y___ N ___ Colic Vision Frequent diarrhea An eye turns in (or out) Y___ N ___ Frequent constipation Concerns about vision Y___ N ___ Stool in pants Uses finger to keep place when reading Y___ N ___ Genitourinary Poor ball skills Y___ N ___ Urinates in pants Speech Wets bed Stuttering Y___ N ___ Drinks excessively Unclear speech Y___ N ___ Excessive urination Repeats what he hears on TV or movies Y___ N ___ Movement Seem clumsy Y___ Avoid balance activities Y___ Seem stiff or awkward in movement Y___ Have difficulty sitting still Y___ Become overly excited following movement Y___ Have difficulty grasping or scissor use Y___ Have difficulty drawing, forming letters or numbers Y___ Y___ Y___ Y___ Y___ N___ N ___ N ___ N ___ Y___ N ___ Y___ N ___ Y___ Y___ Y___ Y___ Y___ Y___ N ___ N ___ N ___ N ___ N ___ N ___ Y___ Y___ Y___ Y___ N ___ N ___ N ___ N ___ N ___ N ___ N ___ N ___ N ___ N ___ N ___ Family History Have any family members had any of the following? Anxiety Disorder Y___ N ___ ADD or ADHD Y___ N ___ Autism/PDD/Asperger’s Y___ N ___ Bipolar Disorder Y___ N ___ Birth Defects Y___ N ___ Diabetes Y___ N ___ Learning Difficulties Y___ N ___ Obessive-Compulsive Disorder Y___ N ___ Reading Disorder (dyslexia) Y___ N ___ Seizures or Epilepsy Y___ N ___ Speech or language problem Y___ N ___ Tourette’s Syndrome Y___ N ___ If so, which family members were affected? ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ 7 Kids Kount Confidential Personal History Please list any medications your child is taking. Medicine Name Dosage frequency ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ ______________________ __________ ______________ Condition requiring medication ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Please feel free to comment on any other concerns or issues you or your child are having that have not already been mentioned above. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________ Signature Relationship to patient __________________ Date 8
