Name Birth date Age

School Grade School Name

Birth History Lbs______Weeks______£ Full term £ Preterm
£ Vaginal £ C/ section £ Reason for C- section
APGARS (If known):
Medications During Pregnancy £ None £ Prenatal Vitamins
£ Other - Please name:

Mom’s Pregnancy Post Natal Complications

£ Uncomplicated
£ Early Labor
£ Hyperemesis (excessive vomiting)
£ Bleeding / £ Diabetes
£ Thyroid problems
£ Pre-eclampsia
£ Physical or emotional trauma / £ None
£ Jaundice
£ Respiratory
£ Cardiac / £ Infections
£ Gastrointestinal
£ Hospitalized. How lonq?

Developmental History Rolled over at Crawled at Walked at

Sat at Talked at Solid food at
Has (s)he stopped or had regression of speech £ No £ Yes

Medical History Symptoms

£ Allergies
£ Asthma
£ Breath-holding spells
£ Chicken pox
£ Colic
£ Dehydration
£ Ear infections
£ none
£ rarely
£ many
£ Eczema
£ Encephalitis
£ Frequent colds / £ Measles
£ Meningitis
£ Passing out (syncope)
£ Pneumonia
£ Previous surgeries
(please list dates)
£ Seizures
£ With fever
£ Without fever
£ Strep throat
£ Tonsillitis / £ Hives
£ Cries easily
£ Nose bleeds
£ Acne
£ Jaundice
£ Diarrhea
£ Wheezing
£ Vomiting spells
£ Joint pains
£ High fevers
£ Dizziness / £ Anemia
£ Low appetite
£ Fatigue
£ Constipation
£ Frequent urination
£ Stomach aches
£ Headaches
£ Warts
£ Hair loss
£ Cough
£ Rashes

Immunizations

£ HIB £ Pneumococcal £ Diptheria £ Pertussis £ Tetanus £ Measles £ Mumps £ Rubella £ Hep B £ Varicella £ Polio EIPV

Other? Any reactions to immunizations? Describe please:

Medications/Supplements

Name

/

Date Started

/

Dose AM Noon PM

/

Still taking it?

/

Date Discontinued

Family History
Relation / Age / State
of Health / Age at Death / Cause of Death / Check (P) if your blood relatives had any of the following and describe their relationship to you
Father / £ Aneurysms______
£ Anxiety______
£ Arthritis, gout______
£ Asthma______
£ Autism______
£ Brain Tumors______
£ Cancer______
£ Cerebral Palsy______
£ Chemical Dependency______
£ Depression______
£ Diabetes______
£ Epilepsy/Seizures______
£ Gonorrhea______/ £ Headaches/Migraines ______
£ Heart Disease______
£ High Blood Pressure______
£ Kidney Disease______
£ Learning Disabilities______
£ Manic Depression______
£ Mental Retardation______
£ Muscle illnesses______
£ Obsessive Compulsive DO______
£ Schizophrenia______
£ Syphilis______
£ Tics______
£ Tuberculosis______
Mother
Brothers
Sisters
Please describe your child’s typical diet:
Breakfast::
Lunch:
Dinner:
Favorite foods:

Academic Performance £ Excellent £ Average £ Poor

Which areas are difficult?

Behavior £ Excellent £ Variable £ Disruptive

Is there any history of:

£ Biting

£ Hitting

£ Head banging

£ Aggressiveness

£ Unable to comfort

£ Odd fascinations

£ Bed Wetting

£ Stuttering

£ Teeth grinding at night

£ Teeth grinding in the day

£ Pulling own hair

£ Nursing difficulty

Sensitivity to

£ sound

£ touch

£ smells

£ lights

How is his/her play? £ Appropriate £ Inappropriate

How does (s)he interact with other children? £ Very well £ Average £ Poorly

Abnormal Movements £ None £ Excessive turning £ Hand flapping £ Other______

Sleep Pattern £ Normal £ Difficulty falling asleep £ Frequent waking £ Nightmares £ Night terrors £ Other______

Vision: Vision tested? £ Yes £ No If yes, what were the findings?______

Hearing: Hearing tested? £ Yes £ No If yes, what were the findings?______

Excessive fears

£ Water

£ Being alone

£ Dark

£ Monsters/ghosts

£ Thunder/Storms

£ Strangers

£ Animals. Which ones?

£ Other

Please briefly describe the reason for your visit: