pediatricadvanced_PatientDemo

Demographics and Medical History Form
Childs First Name*
Childs Last Name*
Date of Birth*

MonthDayYear
Date
Caregiver #1
Name*
Age*
Relationship to child:*
Other
Home Address*
Phone Number*
Email*
example@example.com
Occupation
Caregiver #2
Name
Age
Relationship to child:
Is address different from primary caregiver?

YesNo
If yes, please provide
Phone Number
Email
example@example.com
Occupation
With which caregiver(s) does the child live?

BothMotherFather
Other(s)
example@example.com
Are parents separated or divorced?

YesNo
Primary language spoken in the home?*
Other
Other languages child is exposed to*
Do any other adults live in the home?*

YesNo
Name/relationship (please indicate)
How many children are living in the home
Ages
CHILD'S EVALUATION AND TREATMENT HISTORY:

Please tell us all doctors or specialists involved in your child's care:
Pediatrician Current
Pediatrician Previous
Reason Seen
ENT Current
ENT Previous
Reason Seen
Cardiologist Current
Cardiologist Previous
Reason Seen
Pulmonologist Current
Pulmonologist Previous
Reason Seen
Gastroenterologist Current
Gastroenterologist Previous
Reason Seen
Nephrologist Current
Nephrologist Previous
Reason Seen
Neurologist Current
Neurologist Previous
Reason Seen
Geneticist Current
Geneticist Previous
Reason Seen
Psychologist/Psychiatrist Current
Psychologist/Psychiatrist Current
Reason Seen
Developmental Pediatrician Current
Developmental Pediatrician Previous
Reason Seen
Other
Please check any/all developmental, medical, mental health or behavioral diagnoses your child has received. Please include details on diagnosing physician and age of diagnosis below the checkboxes
Learning disabilitySpeech/Language disorderDown SyndromeCerebral PalsyBronchopulmonary DysphagiaFeeding disorderSeizure disorderOCDSensory integrationODD
ADHDEpilepsyFragile XIntellectual Disability (formerly MRDD)Autism/Asperger/PDDMotor delayTourette/ticsDevelopmental DelayRefluxBehavior/Mental health disorderGenetic syndrome disorder
Type of Behaviour/Mental health disorder
Describe Type of Genetic Syndrome
Other
Physician(s) who Diagnosed
Age(s) of onset
Diagnostic tests: (dates and results, if known)

Please check any special tests, procedures, and/or hospitalizations since birth (MRI, EEG)
EEG (brain wave test)MRIHead UltrasoundAudiology EvaluationCT ScanSleep StudyOphthalmology EvaluationChromosomal/DNA testingBlood test (other than routine)
Other (specify)
Details of results (including dates and age of child at time of testing)
Please list all agencies and intervention services from the past and present, as well as additional details for frequency and specific agencies regarding anyone your child is currently seeing:

	PAST (Select in all the columns this applies)	CURRENT (select in all the columns this applies)
OT
PT
ST
ABA
Counseling
Hippotherapy
Play Therapy

OT: Frequency (# times per week/mth)
OT: Name of Agency or School if provided within school based services/IEP, or list both if applicable
PT: Frequency (# times per week/mth)
PT: Name of Agency or School if provided within school based services/IEP, or list both if applicable
ST: Frequency (# times per week/mth)
ST: Name of Agency or School if provided within school based services/IEP, or list both if applicable
ABA: Frequency (# times per week/mth)
ABA: Name of Agency or School if provided within school based services/IEP, or list both if applicable
Counseling: Frequency (# times per week/mth)
Counseling: Name of Agency or School if provided within school based services/IEP, or list both if applicable
Hippotherapy: Frequency (# times per week/mth)
Hippotherapy: Name of Agency or School if provided within school based services/IEP, or list both if applicable
Play Therapy: Frequency (# times per week/mth)
Play Therapy: Name of Agency or School if provided within school based services/IEP, or list both if applicable
Other: Frequency (# times per week/mth)
Other: Name of Agency or School if provided within school based services/IEP, or list both if applicable
EDUCATIONAL HISTORY
School*
Grade*
Does your child have an IEP?*

YesNo
(If Yes, please remember to bring a copy with you to their evaluation)

Please ensure that if your child is receiving any school-based therapies that you include those in the above chart for all therapy types and frequencies.
Pregnancy: Did mother receive prenatal care during the pregnancy?

YesNo
Were there any complications during pregnancy?*

YesNo
If yes please explain
Were any medications or other methods used to assist with becoming pregnant?

YesNo
If yes, please explain:
Medications prescribed during the pregnancy. Please list
During pregnancy

DrugsAlcoholSmoking
BIRTH HISTORY
Was infant born full term (38 weeks or greater)?*

YesNo
If premature, how early? (weeks)*
If overdue, how late (weeks)*
Birth Weight: LBS*
Birth Weight: OZ*
Type of delivery

SpontaneousCesareanInduced (e.g. Pitocin)Twins/MultipleBreech (feet first)With instruments (e.g. forecasts/vacuum)
Describe any complications during delivery*
Did infant require supplemental oxygen?*

YesNo
If yes, how long:*
Did infant require have seizures*

YesNo
If yes, how long:*
Was infant placed in the NICU?*

YesNo
If yes, how long:*
Length of stay in hospital for Mother (days)
Length of stay in hospital for Infant (days)
Has the infant experienced

JaundicedCyanosis (blue baby)Breathing difficultyFeeding difficulties - breast or bottleColicSeizuresOther
Feeding:*

Breast-fedBottle-fedNutritional Disturbances
DEVELOPMENTAL HISTORY: (*These can vary within normal range)

Please specify the ages completed for each milestone
Rolled over: Typical Age Mastered (6 months) - please list age completed*
Sitting: Typical Age Mastered (6 -7 months) -age completed*
Crawled: Typical Age Mastered (6 -9 months) -age completed*
Walked: Typical Age Mastered (11-13 months) -age completed*
Spoke Single Words: Typical Age Mastered (12 months) -age completed*
ADDITIONAL MEDICAL HISTORY:
Child's current health status:*

ExcellentGoodFairPoor
Please list all medication your child takes:
Medication 1
Frequency
Physician who prescribed
Reason
Medication 2
Frequency
Physician who prescribed
Reason
Medication 3
Frequency
Physician who prescribed
Reason
Medication 4
Frequency
Physician who prescribed
Reason
Does child have any allergies to medication/food?*

YesNo
If yes, please list
Is child up to date on immunizations?*

YesNo
If no, which are missing
Vision impairment
Glasses?

YesNo
Hearing impairment
Hearing aid?

YesNo
Tubes in ears

YesNo
History of ear infections?

YesNo
If yes please explain
Emergency Plans? (i.e. Epipen, seizures)*

YesNo
If yes please explain
DAILY ROUTINES:

How does your child play with siblings or other children their own age?
PoorlyFairly wellWellN/A - Does not play with others
How many hours per night does your child sleep?*
Does your child have any behavior/attention issues?*
Does your child use any of the following at home or at school?

WalkerWheelchairAssistive TehnologyOrthotics
Other
Physical limitations/precautions to be aware of: (i.e. shunt, poor balance, etc.)

YesNo
If yes please describe
Safety concerns we should be aware of:
Self-abusive/injurious*

YesNo
Abusive/aggressive towards others*

YesNo
Run from building premises*

YesNo
Other
Should be Empty:

Caregiver #1

Caregiver #2

ADDITIONAL MEDICAL HISTORY: