Birth History: _________________________________________________________________________

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Describe the problem for which you seek occupational/physical/speech therapy for your child.

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What are your personal goals for your child in occupational/physical/speech therapy?

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Is your child receiving services from anyone else for this problem?

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What medications is your child taking? (prescription and non-prescription)

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Has your child had any medical tests?(MRI, X-ray, EMG, Vision, Hearing, Swallow, etc.)

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Medical History:

Allergies (latex, food, meds, environmental):________________________________________________

Please check if your child has had any of the following problems:

□ Heart Condition

□ Pacemaker

□ Circulatory Problems

□ Diabetes

□ Hypertension

□ Stroke

□ Cancer

□ Neurological Disease

□ Lung Condition

□ Psychological

□ Head Injury

□ Seizures/Epilepsy

□ Fractures

□ Neck Injury

□ Back Injury

□ Hearing Loss

□ Vision Loss

□ Artificial Joint

□ Infectious Disease

□ Osteoporosis

□ Arthritis

□ Surgery

□ Other

Brief history of surgeries and categories checked:

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Within the past year, has your child had any of the following symptoms? (Check all that apply)

□ Chest pain

□ Heart palpitations

□ Persistent or productive cough

□ Hoarseness

□ Shortness of breath

□ Dizziness or blackouts

□ Weakness in arms or legs

□ Other:___________________

□ Falling

□ Difficulty walking

□ Joint pain or swelling

□ Pain at night

□ Difficulty sleeping

□ Loss of appetite

□ Nausea/Vomiting

□ Difficulty swallowing

□ Bowel problems

□ Weight loss or gain

□ Urinary problems

□ Fever/Chills/Sweats

□ Headaches

□ Loss of balance

Brief history of symptoms checked:

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Please describe any other medical history or information related to condition.

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Daily Routine (wake up time, meal times, school, daycare, bed time):

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