Medical History
Please fill out the questionnaire below. If you are filling this out for a child, all questions refer to the child. If you do not know the answer to a question, feel free to leave it blank. Thank you!
MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name:
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Last Visit Date:
For What Reason?
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List all medications you are currently taking and dosages (including any OTC/vitamins):
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Do you have any allergies to medications?
Yes
No |
If yes, please list:
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Ladies, are you pregnant or nursing?
N/A
Yes
No
If yes, what is the due/birth date?
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List significant illnesses, high fevers, injuries, or hospitalizations, including date and any complications:
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Has a neurological evaluation been performed?
Yes
No If yes, by whom?
Results and Recommendations:
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Has a psychological evaluation been performed?
Yes
No If yes, by whom?
Results and Recommendations:
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Has an occupational therapy evaluation been performed?
Yes
No If yes, by whom?
Results and Recommendations:
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If you checked YES to any of the above, please explain:
FAMILY HISTORY
Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?
SOCIAL HISTORY
You may discuss this portion directly with the doctor if you prefer. If so, check here:
The following sections are for our pediatric patients only. Adult patients may skip the remaining sections.
DEVELOPMENTAL HISTORY:
Please list all immunizations child has received and date:
Any reactions to immunizations?
Yes
No
If yes, please explain:
Was there ever any concern over your child's general growth or development?
Yes
No
If yes, why?
Did your child crawl (stomach on floor)?
Yes
No
If yes, at what age?
Did your child creep (on all fours)?
Yes
No
If yes, at what age?
At what age did your child walk?
Was child active?
Yes
No
Speech: First words:
At what age?
Was early speech clear to others?
Yes
No
Is speech clear now?
Yes
No
SCHOOL:
Address of school:
Does your child like school?
Yes
No
Specifically describe any school difficulties:
Has your child changed schools often?
Yes
No
If yes, when and why?
Has a grade been repeated?
Yes
No
If yes, which and why?
Does your child seem to be under tension or pressure when doing school work?
Yes
No
Has your child had any special tutoring, therapy, and/or remedial assistance?
Yes
No
If yes, when and how long?
Where and from whom?
Results:
Does your child like to read?
Yes
No
Does your child read for pleasure?
Yes
No
Overall schoolwork is:
Above average
Average
Below average
Which subjects are:
Above average:
Average:
Below average:
Does your child spend a lot of time/effort to maintain this level of performance?
Yes
No
How much time does your child spend each day on homework?
To what extent do you assist your child with homework?
Do you feel your child is achieving up to potential?
Yes
No
Does the teacher feel your child is achieving up to potential?
Yes
No
GENERAL BEHAVIOR:
Are there any behavior problems at school?
Yes
No
If yes, what?
Are there any behavior problems at home?
Yes
No
If yes, what?
What is your child's reaction to fatigue?
Sag
Irritable
Other
What is your child's reaction to tension?
Avoidance
Irritable
Other
Does your child say and/or do things impulsively?
Yes
No
Can your child sit still for long periods?
Yes
No
Is your child in constant motion?
Yes
No
Please give a brief description of your child as a person:
Is there any other information you feel would be helpful/important in our treatment of your child?