Pediatric History Questionnaire

Completed by (Name and relationship to patient) *

Date *

Childs Name *

Date Of Birth *

Age *

Address *

City *

State *

Zip Code *

Main language used at home *

Other languages used

Email Address *

Secondary Email Address

Preferred Daytime Phone *

Additional Phone Number

Why are you coming for an evaluation and what are your main concerns?*

Has your child been previously evaluated or treated by an Occupational Therapist, Physical Therapist, or Speech Language Pathologist? Date(s)? of Evaluation(s)?*

Please indicate any known adverse/allergic drug and/or food allergies (e.g., penicillin, latex, gluten):*

Please tell us all other doctors or specialists involved in your child's healthcare.

Specialty of Physician
(ENT, GI, Geneticist Pediatrician)

Name of Physician
(First and Last)

Date
Last Seen

Phone
Number(s)

Fax
Number(s)

Please list all medical diagnoses your child has

Diagnosis

Age at time of Diagnosis

Name of Physician who Diagnosed

Please list all medications your child takes:

Medication

Dosage

Route
(Nasal/Oral)

Frequency

Physician
who prescribed

Start Date

Stop Date

Does your child wear glasses or have difficulty seeing? (Please describe)

Results of last hearing evaluation:

Date

Results of last vision evaluation

Date

Please list any tests, surgeries, and/or hospitalizations since birth (MRI, EEG):

Date

Procedure

Reason for Testing

Results of Procedure

Pregnancy

Neonatal

At Moore Pediatric Therapy we focus on the potential of each child and encourage and promote parental partnerships with each therapist.

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