Download Type Here - Faith Pediatric Rehabilitation

Pediatric Patient History Form
General Information
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Child’s Name: __________________________
Date: _______________
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Form completed by: ____________________________
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Relationship to child: ____________
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Gender of child: _____________
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Child’s Birthdate: ______________
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Age: _____________
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Address: ____________________________________________________________________________
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Language(s) other than English spoken at home/childcare: ___________________________________
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Primary language spoken by child: _____________________
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Understood by child _______________
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Current Pediatrician or Family Doctor: ________________________
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Telephone: ________________
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Who referred you to us: _________________________________________________________________
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Does your child have any diagnosis?________________________________________________________
Areas of Concern:
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What is the main reason for your child’s referral? ____________________________________________
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How long has your child had these problems? ________________________________________________
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What have you tried to do to help your child with these problems? ______________________________
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What is your desired outcome? _____________________________________________________________
Revised June 2013
Mother’s History
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Mother’s name: ____________________________
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Work Phone: ________________
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Home Phone: ______________________________
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Occupation: ________________
Email: _________________
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Is email a good way to reach you? ________________
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Place of Employment ______________________
Father’s History:
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Father’s Name: ____________________________
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Home Phone: _____________________________
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Work Phone: _______________ Occupation: _______________
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Is email a good way to reach you? ________________
Emergency Contact Information:
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Last Name: ____________________________
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Relationship: ___________________________
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Work Phone: ___________________________
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Email: _______________
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Place of Employment ______________________
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First Name: ______________________________
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Home Phone: ____________________________
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Cell Phone: ______________________________
Please write any additional remarked you may have regarding your child or address any area of concern
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we may have missed in the space below: _____________________________________________________
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Family History:
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Child currently lives with: _________________________________________________________________
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If this child I adopted, please state child’s adoption age and date of adoption: ____________________
Revised June 2013
Medical History:
Pre-Natal History:
Please check any answer which of the following conditions that occurred during this pregnancy and
explain in space below:
Alcohol Use
Cigarettes
Cocaine
Diabetes
Edema
Emotional
Epilepsy
Fever
High blood pre
Hospitalization
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Infections
Injuries
Marijuana
Medications
Operations
Other drugs
Other illnesses
Toxemia
Vaginal bleed
X-ray studies
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
(Please bold desired answer)
Please explain “Yes” answers:
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Birth History:
Length of Pregnancy:
Age of Mother at birth:
Weight of child at Birth:
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Length of Labor: _________________
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Age of Father at birth: ____________
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Was the child’s birth spontaneous vaginal/ induced vaginal or c-section? _______________________
Please check the following that occurred during pregnancy?
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Toxemia
Maternal fever
Fetal distress
Medications (Please bold desired answers)
Revised June 2013
Child’s Post Delivery Period:
Check any of the following problems that occurred after the child’s birth and explain the amount and
treatment in the space below:
(please bold desired answers)
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Blood transfusion
Cord around neck
Fever
Cyanosis
Hemorrhage (bleeding) in head
Hydrocephalus (water on brain)
Incubator Care
Infection
Jaundice
Poor feeding skills
Poor Muscle Tone
Trouble Breathing
Ventilator
Vomiting/Reflux
Please explain “Yes” answers:
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Number of Days Infant Stayed in Hospital?
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Apgar Scores if known? ________________
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Has your child had any medical procedures?:_____________________________________________
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Dates :______________________Type of procedure:_______________________________________
Please give dates and age of child when procedure occurred: ______________________________
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Has any family member been diagnosed and if so who and what is their diagnosis?
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Revised June 2013
Previous Evaluations:
(Audiologist, behavior specialist, PT, OT, Speech, psychologist, ophthalmologist, neurologist, etc.)?
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Please provide dates, name of provider and results: ______________________________________
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Medications:
Is your child taking any medications?
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Dosage/Frequency? ________________________________________________________________
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Allergies:
Does your child have any allergies? (Skin/food/medication)? If yes what are the allergies?
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Social:
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What does your child enjoy doing the most? __________________________________________
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What does your child dislike? ______________________________________________________
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How easily does your child make friends? ____________________________________________
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Does our child have problems keeping friends? _______________________________________
Has any sudden change occurred in your child’s life? (Divorce, family accident, death)? _____
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Revised June 2013
Sleeping Habits:
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Where does your child sleep? ______________________________________________________
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Does your child have problems falling asleep? ________________________________________
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How many hours per night does your child sleep? _____________________________________
Education:
Does your child attend school? If so name of school?
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Teacher’s Name ____________________
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Grade: ____________________
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Telephone# ________________
Has/Is your child in special education program and if yes name of program? ______________
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Have any class modifications been implemented? If yes what? __________________________
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I certify that all the information provided herein is true and correct
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Parent/Guardian Signature: _______________________________________________________
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Date: __________________
Revised June 2013