Outpatient Rehabilitative Services

Harford Memorial Hospital
501 South Union Avenue
Havre de Grace, MD 21078
Physicians Pavilion II
Suite 514
510 Upper Chesapeake Drive
Bel Air, MD 21014
Sports Medicine & Rehabilitation Center
Y at Abingdon
101 Walter Ward Blvd.
Abingdon, MD 21009
Pediatric History and Survey

Date of Birth: (Month/Day/Year) - -    Age:

Please take a few minutes to complete this health survey for your child.  Your responses will give us very valuable information regarding the health and development of your child and will help us provide better services for you and your child. Thank You.


Current Condition(s) Chief Complaint(s)

Describe the symptom(s) or problem(s) for which you seek therapy for your child

When did the symptom(s) start (date)? / /
Has your child ever had the symptom(s) before? NO YES
Is there a family history of symptoms? NO YES
What did you do for the symptom(s)?
Did the symptom(s) improve? NO YES
What makes the symptoms improve?
What makes the symptoms worse?
What are your goals for your child for therapy?

Are you seeking anyone else for the sympton(s) Check all that apply:
Acupuncturist Massage Therapist Osteopathic physician
Cardiologist Neurologist School physical therapist
Chiropractor Podiatrist School occupational therapist
Dentist Pediatrician School speech therapist
Orthopedist Surgeon Primary care physician
Internist Rheumatologist Family practitioner
Nurse Practitioner Audiologist Other:

Does your child take any prescription medications?
NO YES   Please list them:
Does your child take any over the counter (non-prescription medications)?
Check all that apply:

Advil/Ibuprofen Aleve/Naproxen Other:
Antacids Decongestants Other:
Aspirin Herbal Supplements Other:

Does your child have any known allergies or adverse reactions to any prescription(s) or over the counter medications or food allergies?
NO YES   Please list them:

Clinical Tests:  Within the past year has your child had any of the following tests?
Check all that apply:
Angiogram Doppler Ultrasound Myelogram
Arthroscopy Echocardiogram  NCV(Nerve Conduction Velocity)
Biopsy EEG (Electrocephalogram) Pulmonary function test
Blood Tests EKG Electrocardiogram) Spinal Test
Bone Scan EMG (Electromyogram) Stress Test (e.g.. treadmill, bicycle)
CT Scan  MRI X-rays
Modified Barium Swallow test Other:

Medical History

Has your child ever had or been diagnosed with?
Check all that apply:

Arthritis Broken bones/Fractures Thyroid Problems
Cancer Cerebral palsy Head Injury
Muscular Dystrophy Kidney Problems Heart Problems
Repeated Infections High Blood Pressure Brachial Plexus Injury
Mental Retardation Downs Syndrome Autism
Aspergers Seizures / Epilepsy PDD (Pervasive Developmental Disorder)
Attention Deficit Disorder Skin Diseases Ulcers/Stomach Disorder problems
Lung Problems Stroke Depression
Learning Disabilities Developmental Delay Growth Problems
Blood Disorders Infectious Disease (e.g.. Hepatitis, AIDs) Circulation problems
Diabetes/High Blood Hypoglycemia /Low
Sugar Blood Sugar
ADHD(Attention Deficit Hyperactivity disorder)
Emotional Disturbance Dysgraphia Speech/Language impairment
Cleft palate Other:    

Was your child carried to full term (36-40 weeks gestation)?  NO YES
If no, how many weeks/months gestation:

Within the past year has your child had any of the following symptoms?
Check all that apply:
Chest Pain Loss of Balance Bowel Problems
Heart palpitations Difficulty walking Weight loss/gain
Cough Joint pain or swelling Urinary Problems
Hoarseness Pain at Night Fever/chills/sweats
Shortness of Breath Difficulty sleeping Headaches
Dizziness or blackouts Loss of Appetite Hearing Problems
Weakness in arms & Legs Difficulty Swallowing Difficulty being understood by others

Has your Child ever had surgery? NO YES

Please list them and include approximate dates. :
            Month / Year
Date /
Date /
Date /

General Health Status
Please rate your child’s health  Excellent Good Fair Poor
Has your Child had any major life changes in the past year? (e.g., new baby, death of a loved one, divorce,)
Please explain briefly:

Social/Health Habits
Exercise: Does your child play out doors ? NO YES
If Yes, how many hours on average per week?
How many minutes on average a day?
Is your child involved in community activities (e.g., sports teams, Recreation programs, dance classes) NO YES
If Yes, How many activities ?
How many hours each week?
Does your child have any siblings? If so, what are their ages?
Primary language spoken?
Other languages spoken?
Social History  
Cultural / Religious: Are there any customs or religious beliefs that might affect your child’s care? Please explain,
Education: Does our child struggle academically? NO YES
Has he or she ever been referred for I.E.P. or 504 Plan? NO YES
Is he or she on an educational I.E.P. or 504 Plan? NO YES
If Yes, please bring a copy with you and all pertinent assessments for your first appointment..
Please complete the following developmental milestones checklist as it will help us better serve your child’s needs.
When your child reached the age of three months did he or she?
Follow moving person with eyes while lying on his/her back NO YES
Lift head and chest while lying on his/her stomach NO YES
Grasp rattle when given to the child NO YES
Make sounds (ah/eh/ugh) NO YES
Cry when hungry or upset NO YES
When your child reached the age of six months did he or she?
Clasp hands NO YES
Reach for and grasp objects NO YES
Follow moving object with eyes without moving head NO YES
Respond to voice by turning head in direction of source NO YES
Laugh out loud NO YES
When your Child reached the age of nine months did he or she?
Play with toy actively by moving wrists NO YES
Reach and grasp object with straight elbow NO YES
Crawls and sits up NO YES
Babble NO YES
Make sounds like da, ba, ma, ga, ka NO YES
Imitate sounds you make NO YES
When your child reached the age of 12 months did he or she?
Take objects out of a container NO YES
Clap hands NO YES
Drink from a cup with help NO YES
Stand momentarily NO YES
Walk with one hand held NO YES
Say first word NO YES
Understand short phrases, i.e. “no-no” or “all gone” NO YES
When your child reached the age of 2 years did he or she?
Walk alone NO YES
Pick up toys from a standing position NO YES
Mark paper with crayon NO YES
Grasp and hold a small ball NO YES
Turn 2 to 3 pages at a time NO YES
Speak in two word sentences NO YES
Follow one step directions, i.e. “point to the ______” NO YES
Name at least 5 objects NO YES
When your child reached the age of 3 years did he or she?
Run forward NO YES
Jump in place with both feet together NO YES
Kick ball forward NO YES
String large beads NO YES
Turn pages one by one NO YES
Draw a circle NO YES
Answer simple questions when asked NO YES
Speak in 4 to 5 word sentences NO YES
Understand concepts/pronouns: she, her, he, his, soft, hard, etc. NO YES
When your child reached the age of 4 years did he or she?
Hop on one foot three times NO YES
Bounce and catch a large ball NO YES
Ride a tricycle NO YES
Copy a square NO YES
Recognize most colors NO YES
Tell stories  
When your child reached the age of 5 years did he or she?
Skip and gallop NO YES
Copy a triangle NO YES
Complete a picture of a stick person NO YES
Cut out basic shapes (e.g., triangle/square) with scissors NO YES
Recite nursery rhymes/songs NO YES
Speak in complete sentences NO YES
Follow multiple directions NO YES
Be clearly understood by most people NO YES
Please complete the following sensory motor checklist as it pertains to your child.
Thank You
When considering the sense of touch does your child?
Object to being touched NO YES
Prefer to touch rather than be touched NO YES
Resist wearing certain textures of clothing NO YES
Isolate self from other children NO YES
Frequently bump and push other children NO YES
When considering the sense of hearing does your child?
Seem overly sensitive to sound NO YES
Miss some sounds NO YES
Seem confused about the direction of sounds NO YES
Make loud noises inappropriately NO YES
Have a diagnosed hearing loss NO YES
When considering the sense of smell does your child?
Attempt to smell objects other than food NO YES
Discriminate odors NO YES
React defensively to smell NO YES
Ignore noxious odors NO YES
When considering the sense of vision does your child?
Have a diagnosed vision problem NO YES
Have difficulty following objects with their eyes NO YES
Become excited when confronted with a variety of visual stimuli NO YES
Avoid eye contact NO YES
When considering the sense of taste, does your child?
Act like all foods taste the same NO YES
Explore by tasting NO YES
Dislike foods of a certain texture NO YES
Crave certain flavors (salty, sweet, sour) NO YES
When considering the sense of movement, does your child
Dislike rough housing NO YES
Seem fearful in space (e.g., going up and down stairs, riding a teeter totter) NO YES
Appear clumsy, often bumping into things or falling down NO YES
Prefer fast moving and/or spinning rides NO YES
Seek out spinning/rocking activities NO YES
When considering muscle tone, does your child  
Have any diagnosed muscle problems (e.g., spasticity, flaccidity, rigidity) NO YES
Frequently grasp objects too tightly NO YES
Have a weak grasp NO YES
Tire easily NO YES
Sit or walk with poor posture NO YES
When considering coordination does your child?  
Manipulate small objects with fingers NO YES
Seem accident prone NO YES
Have difficulty with pencil/crayon activities NO YES
Have difficulty dressing and or /fastening clothes NO YES
Have a consistent hand preference/dominance NO YES
Use two hands together when needed(e.g.,playing ball, cutting with scissors) NO YES
Signature of person completing this history:
X _______________________________________________________

This is the end of the history and survey. Thank you! Your information will allow us to better meet the needs of your child.

X _______________________________________________________
Reviewed By