Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pediatric Patient History Form General Information Type Here Type Here Child’s Name: __________________________ Date: _______________ Type Here Form completed by: ____________________________ Type Here Relationship to child: ____________ Type Here Gender of child: _____________ Type Here Child’s Birthdate: ______________ Type Here Age: _____________ Type Here Address: ____________________________________________________________________________ Type Here Language(s) other than English spoken at home/childcare: ___________________________________ Type Here Primary language spoken by child: _____________________ Type Here Understood by child _______________ Type Here Current Pediatrician or Family Doctor: ________________________ Type Here Telephone: ________________ Type Here Who referred you to us: _________________________________________________________________ Type Here Does your child have any diagnosis?________________________________________________________ Areas of Concern: Type Here What is the main reason for your child’s referral? ____________________________________________ Type ______________________________________________________________________________________ Here (separate box from previous line) ______________________________________________________________________________________ Type Here How long has your child had these problems? ________________________________________________ Type Here What have you tried to do to help your child with these problems? ______________________________ Type Here (separate box from previous line) _______________________________________________________________________________________ Type Here What is your desired outcome? _____________________________________________________________ Revised June 2013 Mother’s History Type Here Mother’s name: ____________________________ Type Here Work Phone: ________________ Type Here Home Phone: ______________________________ Type Here Type Here Occupation: ________________ Email: _________________ Type Here Is email a good way to reach you? ________________ Type Here Place of Employment ______________________ Father’s History: Type Here Father’s Name: ____________________________ Type Here Home Phone: _____________________________ Type Here Type Here Work Phone: _______________ Occupation: _______________ Type Here Is email a good way to reach you? ________________ Emergency Contact Information: Type Here Last Name: ____________________________ Type Here Relationship: ___________________________ Type Here Work Phone: ___________________________ Type Here Email: _______________ Type Here Place of Employment ______________________ Type Here First Name: ______________________________ Type Here Home Phone: ____________________________ Type Here Cell Phone: ______________________________ Please write any additional remarked you may have regarding your child or address any area of concern Type Here we may have missed in the space below: _____________________________________________________ Type ________________________________________________________________________________________ Here ________________________________________________________________________________________ ________________________________________________________________________________________ Type Here (separate box from previous line) Family History: Type Here Child currently lives with: _________________________________________________________________ Type Here 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: Type ____________________________________________________________________________________ Here ____________________________________________________________________________________ Type ____________________________________________________________________________________ Here ____________________________________________________________________________________ Type Here ____________________________________________________________________________________ Birth History: Length of Pregnancy: Age of Mother at birth: Weight of child at Birth: Type Here ________________ Type Here ________________ Type Here ________________ Type Here Length of Labor: _________________ Type Here Age of Father at birth: ____________ Type Here Was the child’s birth spontaneous vaginal/ induced vaginal or c-section? _______________________ Please check the following that occurred during pregnancy? 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) 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: Type ____________________________________________________________________________________ Here ____________________________________________________________________________________ Type ____________________________________________________________________________________ Here ____________________________________________________________________________________ Type Here ____________________________________________________________________________________ Number of Days Infant Stayed in Hospital? Type Here Apgar Scores if known? ________________ Type Here _______________ Type Here Has your child had any medical procedures?:_____________________________________________ Type Here Type Here Dates :______________________Type of procedure:_______________________________________ Please give dates and age of child when procedure occurred: ______________________________ Type ___________________________________________________________________________________ Here ___________________________________________________________________________________ Type ___________________________________________________________________________________ Here ___________________________________________________________________________________ Type Here (separate box from previous line) ___________________________________________________________________________________ Has any family member been diagnosed and if so who and what is their diagnosis? ________ Type __________________________________________________________________________________ Here __________________________________________________________________________________ Type __________________________________________________________________________________ Here __________________________________________________________________________________ Revised June 2013 Previous Evaluations: (Audiologist, behavior specialist, PT, OT, Speech, psychologist, ophthalmologist, neurologist, etc.)? Type Here Please provide dates, name of provider and results: ______________________________________ Type ___________________________________________________________________________________ Here (separate box from previous line) __________________________________________________________________________________ Medications: Is your child taking any medications? Type Here Dosage/Frequency? ________________________________________________________________ Type _________________________________________________________________________________ Here (separate box from previous line) _________________________________________________________________________________ Allergies: Does your child have any allergies? (Skin/food/medication)? If yes what are the allergies? Type ________________________________________________________________________________ Here ________________________________________________________________________________ Type ________________________________________________________________________________ Here ________________________________________________________________________________ Social: Type Here What does your child enjoy doing the most? __________________________________________ Type (separate box from previous line) _______________________________________________________________________________ Here _______________________________________________________________________________ Type _______________________________________________________________________________ Here _______________________________________________________________________________ Type Here What does your child dislike? ______________________________________________________ Type (separate box from previous line) _______________________________________________________________________________ Here _______________________________________________________________________________ Type Here _______________________________________________________________________________ Type Here How easily does your child make friends? ____________________________________________ Type Here Does our child have problems keeping friends? _______________________________________ Has any sudden change occurred in your child’s life? (Divorce, family accident, death)? _____ Type ______________________________________________________________________________ Here ______________________________________________________________________________ Revised June 2013 Sleeping Habits: Type Here Where does your child sleep? ______________________________________________________ Type Here Does your child have problems falling asleep? ________________________________________ Type Here How many hours per night does your child sleep? _____________________________________ Education: Does your child attend school? If so name of school? Type Here Teacher’s Name ____________________ Type Here Grade: ____________________ Type Here Telephone# ________________ Has/Is your child in special education program and if yes name of program? ______________ Type Here _______________________________________________________________________________ Type Here Have any class modifications been implemented? If yes what? __________________________ Type (separate box from previous line) _______________________________________________________________________________ Here _______________________________________________________________________________ I certify that all the information provided herein is true and correct TYPE NAME HERE Parent/Guardian Signature: _______________________________________________________ TYPE DATE HERE Date: __________________ Revised June 2013