Infant Assessment and History
  • Infant Assessment and History

    Please fill out this health history information prior to your first appointment.
  • Date
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  • Format: (000) 000-0000.
  • Child's Birth Date
     - -
  • Mother's Birth Date
     - -
  • Child's History

  • Prenatal Care and Pregnancy

  • Any spotting or cramping during pregnancy?
  • Rhogam shot needed?
  • Birth History

  • What type of delivery?
  • Practitioner
  • Did baby need oxygen?
  • Did baby nurse after birth?
  • Medical History

  • Nutrition History

  • How is baby eating?
  • Behavior

  • Is baby able to calm self?
  • Does baby have colic?
  • Co sleep or in a crib?
  • Does baby seem on target with developmental milestones?
  • Has baby been diagnosed with any of the following?
  • Family

  • Does anyone smoke?
  • I understand that Therapy Practitioners do not diagnose illness or disease or psychological disorders or prescribe medicine.  I choose for my child to receive therapy and will keep my therapist informed if any changes occur in their medical status.  If I feel at any time the well-being of my child is being compromised during treatment I will inform my therapist.  Soft tissue and oral motor therapy is a gentle noninvasive treatment which uses bones and tissue to affect the nervous system.  It is not guaranteed to cure a disease of disorder.

  • Date
     / /
  • Should be Empty: