BBPT 2026 Medical History

Medical History
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Name of Person Providing Medical History*

First NameLast Name
MaleFemale
YesNo
Pregnancy & Birth History
Length of Pregnancy*
Birth Weight
APGAR Score
Were there any injuries, illnesses or complications with this pregnancy?*
Were any medications taken during this pregnancy?*
VaginalC-SectionBreechEmergencyCcciput Posterior Position "Sunny Side Up"
Were There Any Complications After Birth? *
Was Your Child Hospitalized After Birth? If Yes, How Long?*
FAMILY HISTORY
Please list any relevant medical history on maternal side of family:*
Please list any relevant medical history on paternal side of family:*
Developmental History
At what age did your child sit independently?*
At what age did your child crawl?*
At what age did your child walk?*
At what age did your child say their first word?*
At what age did your child combine words?*
MEDICAL HISTORY
Please List Any Medical Diagnoses*
YesNo
YesNo
Please describe any vision and/or hearing impairments*
Has your child had any surgeries or hospitalizations?*
Has your child had a Modified Barium Swallow Study? If so, please list the date and results/precautions.*
Does you child take any medication?*
Does your child use any medical or adaptive equipment?*
Does your child see any medical specialists?*
Home Visit Considerations
Are there any behavioral challenges we should be aware of?*
Are there any sensory sensitivities (light, sound, touch, textures)?*
Are there any cultural or family considerations we should be aware of?*
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?*
PRECAUTIONS
Does your child have any allergies?*
Does your child have any dietary restrictions?*
Does your child have any swallowing or choking concerns?*
YesNoNot Applicable
Does your child have a history of seizures or fainting?*
Are there any precautions or restrictions we should know about?*
Therapy History & Goals
Does your child receive any additional therapies? If so, where?*
What are your main goals for your child in this therapy program?*
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Medical History

Pregnancy & Birth History

FAMILY HISTORY

Developmental History

MEDICAL HISTORY

Home Visit Considerations

PRECAUTIONS

Therapy History & Goals