Health History Form

Health History Form

Please provide your health history and relevant medical information.
Client's Full Name

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
If yes, please list allergies below
YesNo
If yes, please list medications below
DiabetesHypertension (High Blood Pressure)AsthmaHeart DiseaseCancerArthritisNoneOther
Describe (Other)
Prenatal CarePregnancy ComplicationsPremature BirthSwallowing/Sucking ProblemsDelivery ComplicationsVision/Hearing Problems at Birth

DEVELOPMENTAL MILESTONES

Rows	6-12 months	13-18 months	19-24 months	After 24 months
Sat up alone
Began walking
Was toilet trained
Said words in a meaningful way
Put words into sentences

he/she does not pronouce words correctlyhe/she uses a limited variety of wordshe/she stuttershe/she does not speak in complete sentenceshe/she does not understand questions and/or instructionshis/her voice quality is poorOther
When was the communication problem first noticed?
Is there a family history of speech, language, fluency, voice, or hearing problem? If yes, please explain:
Familiar adultsUnfamiliar adultsWith peers
YesNo
Has your child been seen by a doctor or been evaluated by or received speech therapy/Occupational therapy from other agencies for his/her communication problem? If yes, please indicate who provided the evaluation and dates:
Please list any surgeries or hospitalizations (include dates if possible)
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact*
Should be Empty: