Pediatric history form - Bronson Total Health Care

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Affix Patient Label Is your child currently taking any medications? No Yes If yes, please list:______________________________ _________________________________________________________________________________________________ Please check any items related to medical history: Coordination problem Balance deficit Muscle Tightness Stroke Heart/Cardiac problems High/low blood pressure Diabetes Asthma Cancer Seizures Feeding problems Reflux Cerebral Palsy Cleft Palate Shunt/Hydrocephalus Brain Injury Sleeping disorder Cranial bleeding Developmental delay Speech Delay Has your child ever been evaluated by:_______________ Neurologist Psychiatrist Audiologist Social Worker Occupational Therapist Physical Therapist Genetic Specialist Other Specialist What were the results of the above evaluations:__________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Developmental History: Developmental Milestones: Please list when your child first: Rolled:_________________ Held bottle:_________________ Smiled:________________ Sat:____________________ Used spoon:_________________ Babbled:_______________ Walked:_________________ Used cup:___________________ Crawled:_______________ Reached for toy:___________ Ate Solid Food:______________ What activities does your child have difficulty with? Paying Attention Sitting Rolling Standing Walking Crawling Picking things up Talking Eating Dressing Endurance Jumping Sleeping Swallowing School Memory Playing with others Understanding Calming Does your child: Avoid certain textures of food Avoid getting messy Dislike being hugged/cuddled Frequently bump/push into others Dislike loud sounds Dislike bright lights Avoid walking barefoot Dislike spinning/swinging Likes spinning/swinging Dislike hair being cut Dislike face being washed Dislike teeth being brushed Difficulty calming self Does your child have a favorite toy? _________________________ Does your child have a favorite position to play in?_______________________________________________________ 9003132 (5/11) Pediatric Outpatient History Page 2 of 4 Peds Use Only
Affix Patient Label Do you use play equipment to position your child? Please explain. _________________________________________ _________________________________________________________________________________________________ Speech and Language Development Please check any items that apply to your child’s speech behavior: Does not speak clearly Has trouble understanding questions Has trouble remembering Throws tantrums Has trouble relating to others Seems to be aware of the problems Shows anger about speech problems Does not follow directions Has trouble sitting still Has trouble using right words Has trouble with behavior Seems uncoordinated Having trouble in school because of speech How does your child usually communicate? (Check all that apply) Pointing Gestures Short phrases Sounds Single words Other (Describe):____________________ Is your child able to understand? (Check as many as possible) Gestures Sentences Words Short phrases Do gestures have to be used for your child to understand words, short phrases or sentences? Yes No Sometimes When did your child say his/her first word?_____________________ Put two words together? ____________________ When did sentences emerge?______________________________ Were they clear?______________________________ How old was your child when you first became concerned?_________________________________________________ Who was first to become concerned? ___________________________________________________________________ 9003132 (5/11) Pediatric Outpatient History Page 3 of 4 Peds Use Only
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Pediatric history form - Bronson Total Health Care

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