PEDIATRIC PATIENT HISTORY

GENERAL INFORMATION:

Date:

Patient name:

Sex:

Male Female

Birth Date:

Age:

Grade:

Address:

City:

State:

Zip:

Father’s Name:

Father’s Address:

City:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Email:

Father’s Occupation:

Mother’s Name:

Mother’s Address:

City:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Email:

Mother’s Occupation:

Marital Status of Parents:

Language(s) spoken in home:

Referral Source:

Phone number:

Address:

Concerns/Reasons for referral:

INSURANCE INFORMATION:

Health Insurance Company:

Policy Holder's Name:

Policy Holder's Date of Birth:

PRIOR EVALUATIONS:

Pediatrician:

Phone:

Address:

City:

Zip:

Dentist:

Orthodontist:

Psychologist:

Physical or Occupational Therapist:

Speech-Language Pathologist:

Other Medical Specialists (Neurologist or Ear-Nose-Throat Physician, etc.)

PRENATAL AND BIRTH HISTORY:

Were there any problems during pregnancy or difficulties at birth?

Is the child adopted?

Child’s age at adoption?

Length of Pregnancy:

Duration of Labor:

Birth Weight:

EARLY FEEDING HISTORY:

Was child breast or bottle fed?

If breast fed, how long?

Were there any difficulties with breast-feeding?

Was a bottle used for supplemental feeding?

If bottle-fed, how long?

Were there early feeding problems such as colic, vomiting, frequent belching, gastro-intestinal discomfort?

Did your child transition to solid foods easily?

Any additional information about early feeding skills:

SUCKING HABITS (please indicate whether this was NEVER a habit, is an ACTIVE habit and if it is resolved and when):

Pacifier:

Thumb:

Finger:

OTHER NOXIOUS HABITS (please indicate whether this was NEVER a habit, is an ACTIVE habit and if it is resolved and when):

Blanket Sucking

Shirt Chewing

Tongue Sucking

Lip Biting

Lip Licking

Lip Sucking

Fingernail/Cuticle Chewing

Hair Chewing

Hair Twisting/pulling

Pencil Chewing

Teeth Grinding

Teeth Clenching

Drooling

Prop chin on palm or fist

Describe any methods used to eliminate any of the habits above:

DEVELOPMENTAL INFORMATION:

Indicate ages at which your child accomplished the following:

Sat alone:

Stood alone:

Crawled:

Walked alone:

Bladder trained:

Dressed self:

First words:

Combine 2 words:

List any concerns with speech and language development:

Describe coordination and balance skills:

Percent of speech understood by parents:

Percent of speech understood by others:

History of speech therapy in the past:

PRESENT EATING HABITS:

Is your child a fast or slow eater?

Does your child drink more than one glass of liquid with meals?

Does your child appear to wash down food with liquids?

Does your child chew food adequately?

Does your child choke easily?

Gag easily?

Does your child belch often?

Does your child have digestive problems?

Is your child a noisy eater (smacking)?

Is your child a messy eater?

Is there audible gulping when swallowing?

Does your child chew with lips apart/mouth open?

Does your child resist foods that are difficult to chew?

Does your child eat a variety of foods, textures, temperatures, flavors or are there foods your child avoids?

Describe any current feeding problems:

Any difficulties with swallowing pills?

DENTAL HISTORY:

Were baby teeth normal?

Were baby teeth lost at normal ages?

Does your child have a history of cavities or periodontal disease?

Have permanent teeth been injured/chipped/extracted?

Any dental anomalies?

Has your child had any orthodontic treatment? Is yes, please report on treatment received:

EDUCATION HISTORY:

Present School:

Grade:

Any special services received at school?

Does your child excel in any subjects?

Does your child struggle in any subjects/areas?

Does your child play any musical instruments?

MEDICAL HISTORY: Please note age at diagnosis, severity and any additional information if needed.

Enlarged Tonsils

Tonsillitis

Tonsillectomy

Enlarged Adenoids

Adenoidectomy

Middle Ear Infections

PE Ear Tubes

Ear Surgery

Hearing Loss

Allergies

Frequent Colds

Upper Respiratory Infections

Nasal Obstruction

Deviated Septum

Sinus Infections

Headaches/Migraines

Seizures

Head Injury

Snoring

Sleeping Issues

Jaw Pain/TMD

GERD-Acid Reflux

Heart Problems

High Fevers/Measles

Mumps

Other medical conditions not included on above chart:

List any current prescriptions:

SOCIAL SKILLS:

List a few of your child’s favorite toys or activities:

Does your child have frequent behavior problems?

What strategies have you used and what seems to be most effective?

How does your child interact with peers?

What are your child’s strengths?

ADDITIONAL INFORMATION:

Are there specific questions you would like answered about your child?

Is there anything else you would like me to know about your child or family?

Signature of person completing form:

Relationship to patient:

Date:

Your information will be encrypted.

PEDIATRIC PATIENT HISTORY

GENERAL INFORMATION:

INSURANCE INFORMATION:

PRIOR EVALUATIONS:

PRENATAL AND BIRTH HISTORY:

EARLY FEEDING HISTORY:

DEVELOPMENTAL INFORMATION:

PRESENT EATING HABITS:

DENTAL HISTORY:

OTHER RELATED QUESTIONS:

EDUCATION HISTORY:

MEDICAL HISTORY: Please note age at diagnosis, severity and any additional information if needed.

SOCIAL SKILLS:

ADDITIONAL INFORMATION: