Pediatric Patient History Form – Faith Pediatric Rehabilitation

General InformationChild’s Name: __________________________ Date: _______________

Form completed by: ____________________________ Relationship to child: ____________
Gender of child: _____________ Child’s Birthdate: ______________ Age: _____________
Address: ____________________________________________________________________________

Language(s) other than English spoken at home/childcare: ___________________________________

Primary language spoken by child: _____________________ Understood by child _______________
Current Pediatrician or Family Doctor: ________________________ Telephone: ________________

Who referred you to us: _________________________________________________________________

Areas of Concern:

What is the main reason for your child’s referral? ____________________________________________

______________________________________________________________________________________

How long has your child had these problems? ________________________________________________

What have you tried to do to help your child with these problems? ______________________________

_______________________________________________________________________________________

What is your desired outcome? _____________________________________________________________

Mother’s History

Mother’s name: ____________________________ Home Phone: ______________________________

Work Phone: ________________ Occupation: ________________ Email: _________________

Is email a good way to reach you? ________________ Place of Employment ______________________

Father’s History:

Father’s Name: ____________________________ Home Phone: _____________________________

Work Phone: _______________ Occupation: _______________ Email: _______________

Is email a good way to reach you? ________________ Place of Employment ______________________

Emergency Contact Information:

Last Name: ____________________________ First Name: ______________________________

Relationship: ___________________________ Home Phone: ____________________________

Work Phone: ___________________________ Cell Phone: ______________________________

Please write any additional remarked you may have regarding your child or address any area of concern

Type 
Here 
Type Here (separate box from previous line) we may have missed in the space below: _____________________________________________________

________________________________________________________________________________________

Family History:

Child currently lives with: _________________________________________________________________

If this child I adopted, please state child’s adoption age and date of adoption: ____________________

Medical History:

Pre-Natal History:

Please check any answer which of the following conditions that occurred during this pregnancy and explain in space below:

Alcohol Use	Yes/No
Cigarettes	Yes/No
Cocaine	Yes/No
Diabetes	Yes/No
Edema	Yes/No
Emotional	Yes/No
Epilepsy	Yes/No
Fever	Yes/No
High blood pre	Yes/No
Hospitalization	Yes/No

Infections	Yes/No
Injuries	Yes/No
Marijuana	Yes/No
Medications	Yes/No
Operations	Yes/No
Other drugs	Yes/No
Other illnesses	Yes/No
Toxemia	Yes/No
Vaginal bleed	Yes/No
X-ray studies	Yes/No

(Please bold desired answer)

Type 
Here 
Type 
Here 
Type Here Please explain “Yes” answers:

____________________________________________________________________________________

Birth History:

Length of Pregnancy: ________________ Length of Labor: _________________

Age of Mother at birth: ________________ Age of Father at birth: ____________

Weight of child at Birth: ________________

Was the child’s birth spontaneous vaginal/ induced vaginal or c-section? _______________________

Please check the following that occurred during pregnancy?

§ Toxemia

§ Maternal fever

§ Fetal distress

§ Medications (Please bold desired answers)

Child’s Post Delivery Period:

Check any of the following problems that occurred after the child’s birth and explain the amount and treatment in the space below:

(please bold desired answers)

§ Blood transfusion Infection

§ Cord around neck Jaundice

§ Fever Poor feeding skills

§ Cyanosis Poor Muscle Tone

§ Hemorrhage (bleeding) in head Trouble Breathing

§ Hydrocephalus (water on brain) Ventilator

§ Incubator Care Vomiting/Reflux

Type 
Here 
Type 
Here 
Type Here Please explain “Yes” answers:

____________________________________________________________________________________

Number of Days Infant Stayed in Hospital? _______________

Apgar Scores if known? ________________

Does your child have any diagnosis? Illness? Or had any medical procedures:

Type 
Here 
Type 
Here 
Type Here (separate box from previous line) Please give dates and age of child when procedure occurred: ______________________________

___________________________________________________________________________________

Type 
Here 
Type 
Here Has any family member been diagnosed and if so who and what is their diagnosis? ________

__________________________________________________________________________________

Previous Evaluations:

(Audiologist, behavior specialist, PT, OT, Speech, psychologist, ophthalmologist, neurologist, etc.)?

Type 
Here (separate box from previous line) Please provide dates, name of provider and results: ______________________________________

___________________________________________________________________________________

__________________________________________________________________________________

Medications:

Is your child taking any medications?

Type 
Here (separate box from previous line) Dosage/Frequency? ________________________________________________________________

_________________________________________________________________________________

Allergies:

Type 
Here 
TypeHere Does your child have any allergies? (Skin/food/medication)? If yes what are the allergies?

________________________________________________________________________________

Social:

Type (separate box from previous line) 
Here 
TypeHere 
 What does your child enjoy doing the most? __________________________________________

_______________________________________________________________________________

Type (separate box from previous line) 
Here 
Type Here What does your child dislike? ______________________________________________________

_______________________________________________________________________________

How easily does your child make friends? ____________________________________________

Does our child have problems keeping friends? _______________________________________

Type 
Here Has any sudden change occurred in your child’s life? (Divorce, family accident, death)? _____

______________________________________________________________________________

Sleeping Habits:

Where does your child sleep? ______________________________________________________

Does your child have problems falling asleep? ________________________________________

How many hours per night does your child sleep? _____________________________________

Education:

Does your child attend school? If so name of school? Grade: ____________________

Teacher’s Name ____________________ Telephone# ________________

Has/Is your child in special education program and if yes name of program? ______________

_______________________________________________________________________________

Type (separate box from previous line) 
Here Have any class modifications been implemented? If yes what? __________________________

_______________________________________________________________________________

I certify that all the information provided herein is true and correct

Parent/Guardian Signature: _______________________________________________________

Date: __________________