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Who is your Primary Care Provider? Who referred you to our office? Please describe the reason for today's visit: ___________________________________ Does your child have any physical or mental disabilities? Does your child wear orthotics? Does your child attend any type of therapy? Does your child walk indepently? Does your child communicate verbally? PREGNANCY AND BIRTH HISTORY: Any complications/infections during pregnancy? ___________________________ Any medications during pregnancy? ___________________________ Where was the baby delivered? ___________________________ Was the baby on time? ___________________________ What was the birth weight? ___________________________ What was the birth length? ___________________________ Did the baby have difficulty starting to breathe? ___________________________ Any problems in the first 3 months of life? ___________________________ Passed hearing screen? ___________________________ Birth History Was the delivery vaginal or cesarean? ___________________________ If cesarean, why? ___________________________ What was the baby's birth weight? ___________________________ Did the baby have any problems right after birth? (infection, low blood sugar, breathing problems, time in the NICU) If Yes, please explain: ___________________________ Did the baby go home with mother from hospital? ___________________________ If No, please explain: ___________________________ Did the baby pass the hearing screen completed at the hospital? ___________________________ Was the baby born at term? ___________________________ If No, how many weeks? ___________________________ Did baby have metabolic screening done?(PKU testing)? Any abnormalities found? If Yes, please explain: ___________________________ Did mother have any illness or problem with pregnancy? If Yes, please explain: ___________________________ During pregnancy did mother smoke? ___________________________ During pregnancy did mother use drugs or medication? If Yes, please explain: ___________________________ During pregnancy did mother drink alcohol? ___________________________ Childs Past Medical History Explain: ___________________________ Has your child had any surgery? ___________________________ Has your child ever been hospitalized? ___________________________ Is your child allergic to any medications? ___________________________ Is your child allergic to any foods? ___________________________ Has your child been seen by a specialist? Who & When? ___________________________ Does your child have or has he/she ever had any of the following? ___________________________ Frequent Ear Infection Problems with ears or hearing Asthma / wheezing Bronchitis Pneumonia Nasal allergies Any heart problem or heart murmur Anemia Bleeding Disorder Blood transfusion Frequent abdominal pain Constipation requiring doctors visits Bladder or kidney infection Bed-wetting (after 5 years of age) Any chronic or recurrent skin problems (Acne, exzema, etc) Seizures Thyroid or other endocrine problems Diabetes Use of alcohol or drugs Celiac disease Concussion / Head Injury Any other significant problems For Girls Only Explain: Has she started a menstrual cycle? Are there problems with her periods? Current Medication Name of Medication Dosage: Developmental History ___________________________ Explain Do you have any concerns about your child's development? ___________________________ Has your child had speech therapy? ___________________________ Has your child had physical therapy? ___________________________ Has your child had occupational therapy? ___________________________ PAST MEDICAL/SURGICAL HISTORY: Where has your child gone for health care? ___________________________ Reason for change? Date of last checkup? Any hospitalizations or surgeries since birth? ___________________________ Any serious injuries? Any history of frequent infections? Any medications taken regularly? Has your child had any allergic reactions to any foods, medications, or insect bites? ___________________________ List any other health problems Does your child have a record of immunizations? ___________________________ Did the baby come more than 2 weeks early or 2 weeks late? ___________________________ Were there any problems during labor or delivery? ___________________________ What was the baby¶s birth weig ht? ___________________________ Were there any problems during the nursery stay? ___________________________ FEEDING AND NUTRITION: For the first six months, breast or bottle fed? If bottle, which formula? Any feeding problems? Does child take vitamins? Is your child’s appetite usually good? ___________________________ DEVELOPMENT/BEHAVIOR: At what age did your child sit alone? ___________________________ At what age did your child walk alone? ___________________________ Did he/she say any words at age 18 months? ___________________________ How does your child compare to others of his/her own age? ___________________________ Below average/average/above average Does he/she get along with other children? ___________________________ Does he/she get in trouble at school? ___________________________ Circle if your child has any of the following: speech problems nail biting discipline problems bad temper thumb sucking > 4 years bed wetting toilet training problems hyperactivity SAFETY/ENVIRONMENT: Is your hot water heater set at 120 degrees? ___________________________ Are there home smoke alarms on each floor? ___________________________ Is there a fire extinguisher in the house? ___________________________ Are there any fire arms in the house? ___________________________ Does your child always wear a safety restraint in the car? ___________________________ Does your child always wear a helmet when riding a bike or skating? ___________________________ Have you seen or consulted specialists, or other health care providers? ___________________________ If yes, please list: ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ Do you have any other concerns at this time? 4. Past Medical History Did mother have any illness during pregnancy? ___________________________ Was she/he saying words by 18 mo? ___________________________ Was the baby born at term (>37 wks)? ___________________________ Does she/he get along with other children? ___________________________ Did the baby have any problems while in the hospital? ___________________________ Does your child always use a car seat/belt? ___________________________ Does your child always use a helmet when skating? ___________________________ Any serious reactions to immunizations? ___________________________ Are there smokers the child is exposed to? ___________________________ Are there guns in the home? ___________________________ Any hospitalizations or surgeries? ___________________________ Primary drinking water supply (including water used to ___________________________ Please list all people living in the child’s home: ___________________________ How is your child’s appetite? ___________________________ Was your child breast fed? ___________________________ Which of the following foods are included in your child’s ___________________________ Did the mother have any problems during pregnancy? ___________________________ Did the baby have any breathing problems at birth? ___________________________ Did the baby become jaundiced? ___________________________ Did the baby go home from the hospital with the mother? ___________________________ Has child had any blood transfusions? ___________________________ How much caffeine does your child consume in a day? (specify type and amount): ___________________________ Does your child have any sleep concerns? ___________________________ Does your child have any stress concerns? ___________________________ Weight Issues? ___________________________ Does your child follow a special diet? ___________________________ Describe your childs actvity/exercise regimen. ___________________________ How many hours of T.V. or video games does your child participate in daily? ___________________________ At what age did the child no longer need diapers during the day? ___________________________ At what age did the child no longer need diapers during the night? ___________________________ Academic History If your child is in school: How is his/her behavior in school? ___________________________ Has he/she failed or repeated a grade in school? ___________________________ How is he/she doing in academic subjects? ___________________________ Does your child have an IEP? ___________________________ |