Pediatric Health History

Date

Patient Name

Sex

Date of Birth

Age

Grade

Address

City

State

Zip Code

FATHER'S INFORMATION

Full Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Father's Occupation

MOTHER'S INFORMATION

Mother's Full Name

Address Same as Father?

Yes No

Address (if different)

City (if different)

State (if different)

Zip Code (if different)

Home Phone

Cell Phone

Work Phone

Mother's email

Mother's Occupation

FAMILY INFORMATION

Marital Status of Parents

Language(s) spoken in the home

REFERRAL INFORMATION

Referral Source

Phone

Full address

Concerns/Reasons for referral

PRIOR EVALAUATIONS

Pediatrician

Phone

Address

City

State

Zip Code

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?

Yes No

Child’s age at adoption

Length of Pregnancy

Duration of Labor

Birth Weight

EARLY FEEDING HISTORY

Was child breast or bottle fed

Breast Fed Bottle Fed

If breast fed, how long?

Were there any difficulties with breast-feeding?

Was a bottle used for supplemental feeding needs?

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

Pacifier

Never Active Resolved

Thumb Sucking

Never Active Resolved

Finger sucking

Never Active Resolved

OTHER NOXIOUS HABITS

Blanket Sucking

Never Active Resolved

Shirt Chewing

Never Active Resolved

Tongue Sucking

Never Active Resolved

Lip Biting

Never Active Resolved

Lip Licking

Never Active Resolved

Lip Sucking

Never Active Resolved

Fingernail/Cuticle Chewing

Never Active Resolved

Hair Chewing

Never Active Resolved

Hair Twisting/pulling

Never Active Resolved

Pencil Chewing

Never Active Resolved

Teeth Grinding

Never Active Resolved

Teeth Clenching

Never Active Resolved

Drooling

Never Active Resolved

Prop chin on palm or fist

Never Active Resolved

Describe any methods used to eliminate any of the habits above

DEVELOPMENTAL INFORMATION

Indicate the approximate ages at which your child accomplished the following:

Sat alone

Stood Alone

Crawled

Walked Alone

Bladder trained

Dressed Self

First words

Combined two 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?

Slow Fast

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

Yes No

Does your child appear to wash down food with liquids?

Yes No

Does your child chew food adequately?

Yes No

Does your child choke easily?

Yes No

Gag easily?

Yes No

Does your child belch often?

Yes No

Does your child have digestive problems?

Yes No

Is your child a noisy eater (smacking)?

Yes No

Messy Eater?

Yes No

Is there audible gulping when swallowing?

Yes No

Does your child chew with lips apart/mouth open?

Yes No

Does your child resist foods that are difficult to chew?

Yes No

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

Eats a Variety Avoids foods

Describe any current feeding problems

Any difficulty swallowing pills?

Yes No

DENTAL HISTORY

Were baby teeth normal?

Yes No

Were baby teeth lost at normal ages?

Yes No

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

Yes No

Have permanent teeth been injured/chipped/extracted?

Yes No

Describe any dental anomalies

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