Medical Office - Health Assessment

Medical Office - Health Assessment

(The first four pages are to be completed by the parent/guardian of the child).

Child’s Name:______DOB:______

Family Physician:______Phone: ______
Physician City/State: ______

Family Medical History:Please listany of the following that have been experienced by members of the child’s family. Please identify which family member. (Ex: parents, grandparents, aunts, uncles, siblings, cousins, etc.).

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Seizures - Who: ______

Learning Disabilities - Who: ______

Headaches/Migraines - Who: ______

Intellectual / Developmental Disabilities - Who:______

Diabetes - Who: ______

Mental Illness - Who:______

Nerve / Muscle Problems - Who: ______

High Blood Pressure - Who: ______

Heart / Cardiovascular Problems - Who:______

Multiple Sclerosis - Who: ______

Visual Impairments - Who: ______

Hearing Impairments - Who: ______

Other: ______

______

Please circle “Y” for YES or “N” for NO:

Is there any relative with symptoms similar to those of your child? Y / N
If yes, who: ______

Did any relative(s) have problems in school? Y / N
If yes, who: ______

Comments on above: ______

Past Medical History of Child:

List any complications with pregnancy, labor, or delivery:______

Mother’s age at delivery: ______Number of previous pregnancies: ______

Child’s birth weight: ______Child’s birth length:______Mode of delivery: ______

How long did your child stay in the hospital after birth?______

Were there any problems immediately following birth?______

Was there any use of prescription medication, drugs, alcohol, or tobacco by the mother during pregnancy?If known, please list: ______

Are there any significant childhood diseases or serious illnesses? Y / N If yes, explain:______

______

Are immunizations up to date? Y / N If no, explain: ______

Were there any reactions to immunizations? Y/N If yes, explain: ______

(Please attach a copy of complete immunization records).

Has there been any head trauma? ______

Has your child had seizures? If yes, explain: ______

List all past hospitalizations:

AgeReason

______

______

______

List all past psychiatric hospitalizations:

AgeReason

______

______

______

List all out-patient and/or in-patient surgical procedures:

Age Reason

______

______

______

Please provide your child’s last:

Hearing evaluation: Date______Results:______

Dental exam: Date______Was sedation required? ______

Vision Screening: Date______Results:______

Has your child ever had any of the following diagnostic procedures?

EEG (brain wave): Y or N; If Yes, please give date of procedure and results: ______

______

CT scan: Y or N; If Yes, please givedate of procedure and results:______

______

MRI scan: Y or N; If Yes, please givedate of procedure and results: ______

______

High Resolution Chromosome Testing: Y or N; If Yes, please givedate of procedure and results:

______

______

Fragile X testing: Y or N; If Yes, please givedate of procedure and results: ______

______

Chromosomal Micro Array: Y or N: If Yes, please givedate of procedure and results: ______

______

Are there any other diagnostic and/or genetic evaluations or procedures? Please explain.

______

Current Medications:

Medication

/ Dosage / Reason Prescribed

Current Alternative/Supplements:Please note, without supporting scientific validation, these may not be continued at Heartspring. (See Parent Handbook for further information).

Supplement

/ Dates Used / Reason For Use / Reason Discontinued

Past Medications:Provide a complete list of PAST medications & reasons for discontinuing.

Medication

/ Dates Used / Reason Prescribed / Reason Discontinued

How does your child take his/her medication(s)?

□ Swallows with drink – Explain: ______

□ Crushed in food/drink – Explain:______

□ Liquid medications only – Explain: ______

□ Other - Explain: ______

List any past/current alternative diet(s), procedures or interventions used with your child: (Please note that without supporting scientific validation, these may not be continued at Heartspring. See Parent Handbook for further information.)______

______

Please list your child’s age below, if applicable:

First received early intervention? _____
Began receiving special education services?_____

Receiveda developmental/psychiatricdiagnosis? _____

-- What diagnosis was received? (Circle all that apply and indicate age at time of diagnosis).

Developmental Disability – Age:_____Autism Spectrum Disorder – Age: _____

ADHD – Age: _____Depression – Age: _____

OCD – Age: _____Bi-Polar – Age: _____

Anxiety – Age: _____Seizures – Age: _____

ODD – Age: _____Mood Disorder – Age:_____

Other diagnosis: (please list)______

Professional

/ Dates Seen / Currently Treating? / Name of Professional
Developmental Pediatrician
Pediatric Neurologist
Child & Adolescent Psychiatrist
Child Psychologist
Other – Specialist (ENT, Gastroenterologist, etc.)

Does your child have frequent problems with any of the following?

□ Allergies□Frequent sore throat/colds
□Earaches□Skin problems (acne, eczema, rashes)
□Bowel movements (constipation or loose stools)

Have there been any major changes at home that might affect your child while at Heartspring?

______

______

______

(Parent/Guardian Signature) (Date)

This assessment is to be performed by a licensed physician, physician’s assistant

or nurse approved to perform health assessments.

Student Name:______DOB:______

Past Health History: (Please describe developmental illnesses or attach dictated summary).

______

______

______

______

Allergies:______

Current medications: (including doses and frequency)______

______

Nutritional status:______Prescribed diet: ______

Physical Examination:Height:______Weight:______

For the following, record positive findings only:

Head:______Abdomen:______

EENT:______GU:______

Teeth:______Gyn:______

Heart:______Skeletal:______

Lungs:______Neurological:______

Screening Tests: For the following, please list date and completed results (if available, attach copies of results): Vision:______Hearing:______Dental:______

Lab results:CBC: ______CMP: ______TSH: ______RPR: ______Hep panel: ______UA: ______

Diagnosis:______

______

______

Recommendations:______

______

______

Do you see this child for regular health supervision?______

______

(Physician Signature) (Date)

______

(Print Name)(Subspecialty)

Please return completed form to admissions at fax #: 316-634-8875 or

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