Health History

Client’s Name

Address:

City:

State:

Zip Code:

Home Tel:

Cell:

Work:

Email Address:

Birth Date

Age:

Diagnosis (if any):

Referred by:

Referrer Address:

REFERRAL INFORMATION

Father’s/Caregiver’s Name:

FATHER RELATIONSHIP TO CHILD

Biological Adoptive Step Foster Other

Mother/Caregiver Name:

MOTHER RELATIONSHIP TO CHILD

Biological Adoptive Step Foster Other

If both primary caregivers work, who cares for the child?

Other Caregiver Address:

Other Caregiver Phone #

When is the client in this childcare facility?

Predominant Language Spoken in the Home

PRIMARY INSURANCE

Name, address, phone number of Insurance Company:

Relationship to client:

Policy Holder’s Date of Birth::

Policy Holder’s ID Number:

Patient ID # (if different than Policy Holder’s ID):

Group Number:

FAMILY HISTORY

Client lives with: (1) Both Parents (2) Mother (3) Father (4) Other:

Names and ages of brothers and sisters:

Is there any history of speech, language, and/or hearing problems in other family members? If so, please describe:

Please explain any stressors checked above

Has your child experienced any of the following issues? Please check if you have any concerns.

Nursing or Bottle-Feeding Issues as a Baby

Painful nursing or shallow latch

Poor weight gain

Reflux or spitting up

Unable to hold pacifier

Milk dribbling out of mouth

Poor Supply

Nipple shield required for nursing

Clicking or smacking noise when eating

Other: (specify below)

Sleep Issues

Sleeps in strange positions

Kicks and flails around at night

Wakes easily or often

Wets the bed

Wakes up tired and not refreshed

Grinds teeth while sleeping

Sleeps with mouth open

Snores while sleeping (how often, describe below)

Gasps for air or stops breathing (sleep apnea)

BIRTH HISTORY (for the child being evaluated):

1. Hospital where born + city + state

2. Pediatrician’s Name

3. Pediatrician’s Phone number

4. Gestational Age at time of delivery (or # weeks early or late)

5. What were the baby’s APGAR scores? 1 min and 5 min

6. What was the baby’s birth weight and length?

What was the condition of the infant while in the nursery? Please indicate by placing a checkmark in the column and explain in box below check marks if any boxes were checked (what month, why, what, what occurred, how treated etc):

Please describe any checked boxes above

MEDICAL HISTORY

It is very important to have as complete a medical history for the client as possible. Please fill out the check boxes below, making sure you include an explanation for any checked boxes. Please fill in detail in the text box below the check boxes. In your explanation, please include the client’s age(s) if relevant, any diagnoses made, and any treatments that have occurred.

If any boxes above were checked, please provide detail here.

Hospitalizations or Surgeries (please include date and type of procedure(s))

PRESENT HEALTH STATUS:

Most recent Height/Weight and Date

Please note any illnesses for which the client is currently being treated, including their current medications

FEEDING HISTORY:

1. Please explain, in your own words, the client’s current feeding problem (if any)

2. Was the client breast fed?

From when to when?

Was the client bottle fed?

From when to when?

Please describe the client’s initial skill on the breast and/or bottle:

3. During these early feedings did the client frequently arch, cry, spit up, gag, cough, vomit or pull off of the nipple? Circle any behaviors you saw and describe when they would happen, why and for how long:

4. Describe how the weaning process from the breast and/or bottle went, and why the client was weaned:

5. At what age did the client transition from baby cereal?

Baby food?

Finger Food?

Transition fully to table food

Please describe how these transitions were handled by the client, especially if any difficulties occurred

6. Has the client ever been on any type of special diet (other than previously described)?

If yes, please describe the type of diet, at what ages, why, and the client's response:

DEVELOPMENTAL/SOCIAL HISTORY

We would like to have information about the client’s developmental milestones. INDICATE THE AGE when the client first performed each of the following INDEPENDENTLY. If you can not recall/find a specific age, please mark whether you believe your child accomplished the milestone early, on time or late. If the client has not yet achieved the milestone, write NA . Please also rate your estimation of the quality of your child’s skills.

Smiled (age)

If you cannot remember the age, was the child...

Early On Time Late