Harford
Memorial Hospital
501 South Union Avenue
Havre de Grace, MD 21078
443-843-5331
Physicians Pavilion II
Suite 514
510 Upper Chesapeake Drive
Bel Air, MD 21014
443-643-3257
Sports Medicine
& Rehabilitation Center
Y at Abingdon
101 Walter Ward Blvd.
Abingdon, MD 21009
443-409-0051
Pediatric History and Survey
Name:
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:
Medications
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:
Allergies
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
Other:
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,)
NO
YES
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 _______________________________________________________
______________
Signature
Date
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 _______________________________________________________
