Pediatric Patient History
Fields marked with an * are required

GENERAL INFORMATION
Date *
Sex *
Birth Date of Child *

PREVIOUS/OTHER EVALUATIONS

Has your child ever been examined by any of the following professionals (please add any not listed):
Audiologist


Currently under care?
Behavior Specialist


Currently under care?
Developmental Pediatrician


Currently under care?
Diagnostician


Currently under care?
Neurologist


Currently under care?
ECI


Currently under care?
ENT


Currently under care?
Occupational Therapist


Currently under care?
Ophthalmologist


Currently under care?
Physical Therapist


Currently under care?
Psychologist


Currently under care?
Social Worker


Currently under care?
Speech Pathologist


Currently under care?
School District Specialist(s)


Currently under care?


Currently under care?

DIAGNOSTIC/LABORATORY TESTS

Has your child had any of the following procedures? (Please add any additional tests if not listed.):
EEG (brain activity)


EKG (heart activity)


CT Scan


MRI


Genetic Testing


Swallow Function Study (MBS)


Microarray Analysis


Bloodwork (not routine)


Additional Test


Additional Test


Has your child or any family member been diagnosed with any of the following:
ADD/ADHD
Anxiety
Autism Spectrum Disorder
Cleft Palate or Lip
Chronic Ear Infections
Fine Motor Delays/Issues
Genetic Syndrome/Disorder
Gross Motor Delays/Issues
Hearing Problem
Intellectual Disability
Learning Disability
Psychosocial Disorders
Sensory Processing Disorder
Speech or Language Problem

AREAS OF CONCERN

FAMILY HISTORY
Child currently lives with: (please check all that apply)


Gender
Living in Household


Gender
Living in Household


Gender
Living in Household


Gender
Living in Household


Gender
Living in Household

BIRTH HISTORY

Pre-Natal History:
Please indicate which of the following conditions occurred during this pregnancy and explain (month, amount, treatment, etc.) in space below:

Delivery History:
Type of birth
Baby’s presentation
Please indicate if any of the following problems occurred during/after labor

Post Delivery History:
Please indicate if any of the following problems occurred after the child’s birth and explain the amount and treatment in the space below

Infancy History:
Please indicate if any of the following characteristics were present in your baby to a significant degree during the first few years of life

MEDICAL HISTORY
Accidental poisoning
Adenoidectomy
Allergies (seasonal)
Anemia
Asthma
Bed wetting
Constipation/Diarrhea
Cerebral Palsy
Chicken Pox
Colds
Concussion
Coma
Coma
Croup
Diabetes
Ear infections
Encephalitis
Excessive vomiting
Falls frequently
Flu
Headaches
Head injury/trauma
Hospitalizations
Lost consciousness
Measles
Meningitis
Mumps
Other infections
PE tubes
Persistent high fever
Pica (eat nonfood items)
Pneumonia
Poor muscle tone
Reflux
Seizures
Sinusitis
Sleep problems
Staring spells
Stomach aches
Stitches/lacerations
Surgery
Tics
Tonsillitis
Tonsillectomy
Trauma (broken bones)
Tremor

Allergies
Does your child have any known skin allergies, including allergies to latex?
Does your child have any known food allergies?
Does your child have any known allergies to medications?
Is your child currently taking medication?


Start Date


Start Date


Start Date


Start Date


Start Date

Hearing/Vision:
Date of last vision exam
Vision problem?
Has the following
Date of last hearing exam
Hearing problem?
Has child ever used
Has your child ever been diagnosed with an auditory processing disorder?
Do you question your child’s ability to understand directions or conversations?

Listening Habits

Is child able to:
Hear on the telephone
Hear radio/stereo/TV
Hear one-on-one
Hear in groups
Understand in quiet
Understand in noise (teacher’s directions)

DEVELOPMENTAL HISTORY

Speech/Language Milestones: Please list the approximate age your child:

*Write N/A for skills above your child’s age expectation and SW if your child is still working on a skill.
Did your child’s speech/language development seem to stop?

Speech/Language Skills
What is the primary method(s) your child uses for letting you know what he/she wants? (Please check)
Which of the following best describes your child’s speech? (Please check)

Is your child aware of his/her communication difficulties?
Does your child have difficulty producing certain sounds?
Does your child “get stuck” when attempting to say a word?
Do you have concerns about your child’s voice?
Which of the following do you think you child understands? (check all that apply)

Motor Skills & Self-Care Milestones

Please list the approximate age your child was able to:

*Write N/A for skills above your child’s age expectation, SW if your child is still working on a skill and NW for any skills you want evaluated and/or addressed in therapy.<

Eating Habits
Please check any of the following feeding difficulties your child had or currently has.
How would you rate your child’s appetite?
Is your child a picky eater?

Does your child still have a pacifier?
Does your child still suck his/her thumb?
What utensils does your child use independently?
How does your child take in liquid?

Sleeping Habits:
Where does your child sleep?

Does your child have problems falling asleep?
Does your child wake up in the middle of the night?

Behavior:
Please check any of the following behaviors that your child displays frequently or intensively.
Have any of the following events occurred within the past 12 months?

Social Skills:
Does your child make friends easily?
Does your child get along well with others?
Does your child get along best with

EDUCATION
Class placement

Has your child ever been retained?

Has your child ever been in any of the following programs or received any of these services in school, and if so, how long?
PPCD
ECI
ABA
Resource Room Services
Life Skills Class
Content Mastery
Gifted and Talented
Speech Therapy
Occupational Therapy
Physical Therapy
Adapted Physical Education
Counseling
Self-Contained Class
Other
Have any instructional modifications been attempted? Please check all that apply.
Date

RELEASE OF INFORMATION

I give my written permission for Speech and Motion Therapy to Contact/release medical, speech, and occupational therapy information regarding my child.
Date