Medical History
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Name of Person Providing Medical History
*
First Name
Last Name
Gender
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Male
Female
Are Vaccinations Current?
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Yes
No
Pregnancy & Birth History
Length of Pregnancy
*
Birth Weight
APGAR Score
Were there any injuries, illnesses or complications with this pregnancy?
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Were any medications taken during this pregnancy?
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Delivery
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Vaginal
C-Section
Breech
Emergency
Ccciput Posterior Position "Sunny Side Up"
Were There Any Complications After Birth?
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Was Your Child Hospitalized After Birth? If Yes, How Long?
*
FAMILY HISTORY
Please list any relevant medical history on maternal side of family:
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Please list any relevant medical history on paternal side of family:
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Developmental History
At what age did your child sit independently?
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At what age did your child crawl?
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At what age did your child walk?
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At what age did your child say their first word?
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At what age did your child combine words?
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MEDICAL HISTORY
Please List Any Medical Diagnoses
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Does your child have any vision impairments?
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Yes
No
Does your child have any hearing impairments?
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Yes
No
Please describe any vision and/or hearing impairments
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Has your child had any surgeries or hospitalizations?
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Has your child had a Modified Barium Swallow Study? If so, please list the date and results/precautions.
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Does you child take any medication?
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Does your child use any medical or adaptive equipment?
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Does your child see any medical specialists?
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Home Visit Considerations
Are there any behavioral challenges we should be aware of?
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Are there any sensory sensitivities (light, sound, touch, textures)?
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Are there any cultural or family considerations we should be aware of?
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Is there anything else we should know about your home, your child, or your family routine that would help us make therapy safe and effective?
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PRECAUTIONS
Does your child have any allergies?
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Does your child have any dietary restrictions?
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Does your child have any swallowing or choking concerns?
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If your child has a diagnosis of Down Syndrome, has he/she been diagnosed with Atlantoaxial instability?
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Yes
No
Not Applicable
Does your child have a history of seizures or fainting?
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Are there any precautions or restrictions we should know about?
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Therapy History & Goals
Does your child receive any additional therapies? If so, where?
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What are your main goals for your child in this therapy program?
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Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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