FAMILY AND MEDICAL HISTORY FORM

FORM COMPLETED BY:

Date completed:

PART 1: CHILD’S GENERAL INFORMATION

PATIENT’S FULL NAME:

Last Name, Given Name, Preferred Name

DATE OF BIRTH:

Gender

Male Female

Preferred Pronouns

HOME ADDRESS (street, city, state, zip code)

HOME PHONE:

PREFERRED METHOD OF CONTACT

HOME CELL EMAIL

Insurance Carrier

Please upload front and back of the insurance card

Insurance ID Number

Insurance Group Number

Insurance Policyholder Name

Insurance Policyholder Relationship to Patient

Insurance Policyholder Date of Birth

PATIENT'S PRIMARY PEDIATRICIAN NAME and NAME OF CLINIC:

DIAGNOSIS:

ALLERGIES / PRECAUTIONS:

PRIMARY LANGUAGE SPOKEN AT HOME:

REFERRAL SOURCE:

PARENT / PRIMARY CAREGIVER INFORMATION:

Parent 1:

Please upload photo ID at the end of the document

DATE OF BIRTH:

PHONE NUMBER:

Okay to leave messages?

Yes No

EMAIL ADDRESS:

Gender

Male Female

RELATIONSHIP TO CHILD:

Biological Adoptive Step Foster Other

Parent 2:

DOB:

Sex

Male Female

RELATIONSHIP TO CHILD:

Biological Adoptive Step Foster Other

PHONE NUMBER:

Okay to leave messages?

Yes No

Parents' Marital Status

If parents are not married, describe physical custody:

Sole Joint

If parents are not married, describe legal custody:

Sole Joint

EMERGENCY CONTACT INFORMATION (other than parent/primary caregiver):

NAME:

PHONE NUMBER:

PHONE NUMBER 2:

RELATIONSHIP TO CHILD:

ADDRESS:

CURRENT SCHOOL INFORMATION:

SCHOOL NAME:

GRADE:

ADDRESS:

CITY:

STATE:

PHONE:

SPECIAL EDUCATION SERVICES:

TEACHER (S):

OTHER PERSONS LIVING IN THE CHILD’S HOUSEHOLD:

Please list names, ages, sex, and relationship to child:

PART 2: PREGNANCY AND BIRTH HISTORY

Please list all pregnancies, birth weight, and any delivery, health or developmental problems

PRENATAL HISTORY:

List any problems getting pregnant:

Prenatal care started:

Weight gained / loss (in lbs):

List all prescription medications taken including any over the counter medications (vitamins, antacids, cold medications, aspirin, etc.). List the name, dosage, and amount:

List any cigarettes, caffeine, street drugs taken (how much a day and when in pregnancy):

Did you have any complications during this pregnancy (describe the month, what occurred, how treated):

CHILD’S BIRTH HISTORY:

Hospital name:

City:

State:

Gestational age at time of delivery:

Infant age only

Length of hours in labor:

Any type of labor stimulation and what was used?

List any medications or anesthesia (name, type, and amount) used during delivery (include pain relief, anti-vomiting, sedation and anesthesia):

Type of delivery:

Vaginal (presentation Head / Face / Breech / Transverse) Cesarean Section: elective / emergency

Reason for C-section

Assistance: Forceps / vacuum / other

For any item checked "Yes" please provide an explanation (what occurred, how treated):

How soon after the delivery did you see your baby?

Please list child's APGAR scores at 1 min and 5 min:

Birth Weight:

If you don't know put N/A

Birth Length:

Number of days spent in the nursery?

Number of days spent in the NICU?

For any item checked "Yes" please provide an explanation (what occurred, how treated):

PART 3: MEDICAL HISTORY OF CHILD

For any item chosen please provide an explanation (diagnosis, how treated):

SURGERIES / HOSPITALIZATIONS (include dates and reasons):

DIAGNOSTIC PROCEDURES COMPLETED BY: List specialist name, clinic, and procedure performed.

GASTROINTESTINAL (GI):

ENT (ear, nose, and throat):

ALLERGIST:

SWALLOW STUDY/SCANS:

NUTRITION OR LACTATION CONSULT:

PRESENT HEALTH STATUS:

Height =

Weight =

Percentile =

List current illnesses and medications:

PART 4: NUTRITIONAL HISTORY

Describe any difficulties your child experiences during feedings briefly from birth including CURRENT difficulties: (breast/bottle fed, when weaned, solids/table foods, colic/food allergies, growth/nutrition problems)

Describe a typical:

Breakfast:

Lunch:

Dinner:

Can the individual safely manage:

Regular liquid

Thickened liquid

Regular table food

Soft table food

Does the individual prefer certain food or liquid tastes, textures, or temperatures? Describe.

Describe all items that are marked:

What eating/drinking methods does the individual use (breast, bottle, G-tube, spoon, cup, etc.)? Include any specialized equipment being used.

Does the individual self-feed or is the individual fed by someone else?

Where and how is the individual positioned when eating and drinking (chair, in bed, special seat)?

Does the individual eat and drink enough in a reasonable amount of time?

Does your child have regular bowel movements?

Has the individual gained or lost weight suddenly? Explain.

Is feeding enjoyable for your child?

Yes No

Rate the stress level affected by feeding times by the caregiver and individual:

CAREGIVER

No Stress Mild Stress Moderate Stress High Stress

Individual

No stress Mild stress Moderate stress High stress

Please explain:

PART 5: DENTAL HISTORY

Describe the individual’s dental history/needs.

Has the individual had oral motor treatment (e.g., oral massage, brushing, exercises/activities)? Describe.

Does the individual:

chew on the following:

Toys

Straws

Pens/pencils

Fingernails

Tongue

Other

suck his/her:

Thumb

Fingers

Tongue

Pacifier

Blanket

Other

During sleep does the individual: mouth breathes / Snore / Grind teeth / Other?

Does your child drool?

Yes No

Has your child had tongue or lip tie frenectomies?

Yes No

If yes: Date and name of Provider who Completed the Procedure:

Did you have follow-up appointments with body worker:

Yes No

What kind of body worker?

Chiropractor

Physical Therapist

Craniosacral Therapist (CST)

Doctor of Osteopathy (DO)

Were you instructed to complete stretches:

Yes No

Did you have more than one frenectomy:

Yes No

If yes, how many, name of provider who did the procedures, and dates of procedures?

PART 6: DEVELOPMENTAL HISTORY AND MILESTONES

Indicate the age that your child first did each of the following INDEPENDENTLY. Also indicate whether your child performed this action EARLY, ON TIME, or LATE. If you can not recall a specific age, please mark whether you believe your child accomplished the milestone early, on time or late.

Smiled

Held head up

Rolled over

Reached for an object actively

Transferred object between hands

Sat unsupported

Crawled

Stood alone

Walked by self

Said first words

Threw objects actively

Ran by self

Followed simple 1 step directions

Said 2-3 phrases

Ate unaided with a spoon/fork

Dressed self

Rode bicycle without training wheels

Caught a thrown object

Demonstrated handedness (which?)

Knew colors

Counted to 5

Knew alphabet

Bladder trained - days

Bladder trained - nights

Bowel trained

Do you feel your child was “faster” or “slower” than his/her peers in any other way? Please explain.

If your child is in school, please describe any difficulties or strengths in reading, writing or spelling:

Has your child had problems with any of the following (beyond expected for child’s age):

For any behavior marked above, please explain.

PART 7: FAMILY MEDICAL HISTORY

For any medical problem marked above, please indicate if it was the mother or father and please explain. Include medications, surgeries, hospitalizations.

PART 8: COMMUNICATION HISTORY

What language(s) is spoken in the home? If there are two languages or more, what percentage of each language is spoken during the day?

How does the individual currently communicate (use of gestures, sign language, picture symbols, word or alphabet board, etc.)? Please describe.

What are the individual’s current difficulties with speech, language, and communication? Describe.

Has the individual received speech-language therapy in the past?

Does the individual currently receive speech-language therapy? School or Private? Describe treatment goals.

Does the individual have a history of hearing difficulties (e.g., middle ear infections, hearing loss, etc.)? Please describe. If yes, when was the last hearing assessment?

Is the individual’s speech intelligible to the following people?

Familiar people

Unfamiliar people

Does the individual appear frustrated if he/she is not understood? Please describe.

Describe your concerns and what you hope to take from this evaluation:

ADDITIONAL COMMENTS SECTION: Is there anything else that you would like us to know about your child that may affect our approach to therapy (incl. any food restrictions/diets, religious beliefs, routines, sensitivities)?

Files Please upload any additional documents you would like to share with the OT, PT or SLP

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Insurance Card Please upload front and back of the insurance card

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Photo ID Please upload picture of a photo ID (drivers license, passport, state issued ID)

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