medical history€¦ · 2901 finley rd. ∙ suite 101 ∙ downers grove, il 60515 telephone:...

2901 Finley Rd. ∙ Suite 101 ∙ Downers Grove, IL 60515 Telephone: 630.792.1800 ∙ Fax: 630.792.1801 www.milestones4kids.com

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MEDICAL HISTORY

Today’s Date: ____________________________ Completed By:________________________________________

Child’s Name: ___________________________ Date of Birth: _____________ Age: _________ Gender: M / F

FAMILY MEMBERS – Detailed information

Name Age Sex Adopted Occupation Handedness

Father : _______________ _____ _______ yes no __________________ R L

Step Father: _______________ _____ _______ yes no __________________ R L

Mother: _______________ _____ _______ yes no __________________ R L

Step Mother: _______________ _____ _______ yes no __________________ R L

Children: _______________ _____ _______ yes no __________________ R L

_______________ _____ _______ yes no __________________ R L

_______________ _____ _______ yes no __________________ R L

Marital Status of Parents: ____ Married ___ Separated ____ Divorced ____ Other

What language(s) is spoken at home? ___________________________________________________________________

Are there other individuals or family members living at home? (other than immediate family)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

PHYSICIAN INFORMATION:

Child’s Physician’s or Health Care Providers (including Primary Care Physician):

Pediatrician: _______________________________________________________ Phone: ____________________

Address: __________________________________________________________________________________________

Other Providers:

Name: _____________________ Profession: _________________________ Phone: ____________________

Address: __________________________________________________________________________________________

Name: _____________________ Profession: _________________________ Phone: ____________________

Address: __________________________________________________________________________________________

Date of Child’s Last Medical Checkup: ____________________ Height: ____________ Weight: _________

Are there any medical precautions the therapist should be aware of when working with your child?

__________________________________________________________________________________________________

__________________________________________________________________________________________________


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MEDICATIONS

List any medications your child has received in the past:

Medication: _____________________ Purpose: ___________________ When Taken: ________________




List any medications your child is currently taking, its purpose and frequency of dosage:





PERSONALITY PROFILE

What are your child’s gifts/strengths? __________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What do you enjoy most about your child and family?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What are the presenting problems for your child? (all categories below may not apply.)

Academic: _________________________________________________________________________________________

__________________________________________________________________________________________________

Activities of Daily Life (e.g. eating, dressing) _____________________________________________________________

__________________________________________________________________________________________________

Communication: ____________________________________________________________________________________

__________________________________________________________________________________________________

Motor: ____________________________________________________________________________________________

__________________________________________________________________________________________________

Play: _____________________________________________________________________________________________

__________________________________________________________________________________________________

Relationships: ______________________________________________________________________________________

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Sensory: __________________________________________________________________________________________

__________________________________________________________________________________________________

Other: ____________________________________________________________________________________________

__________________________________________________________________________________________________

What kind of interests and activities does your child have? (hobbies, sports, clubs)

Please list them in order of preference beginning with the favorite activity.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Has your child been diagnosed with (PLEASE CHECK ALL THAT APPLY)

____ ADD

____ ADHD

____ Anxiety Disorder or Mood Disorder (specify)_________________________________________________________

____ Autistic Spectrum Disorder

____ Cognitive Delay

____ Down Syndrome

____ Dyslexia

____ Emotional disorder (specify)______________________________________________________________________

____ A Syndrome (specify)___________________________________________________________________________

____ Learning Disabilities (specify if possible)____________________________________________________________

____ Sensory Processing Disorder or Sensory Integration Dysfunction

____ Other (specify)_________________________________________________________________________________

Please note who it was that provided the diagnosis and based on what criteria i.e., test scores, comprehensive clinical

evaluation, genetic study, etc)__________________________________________________________________________

__________________________________________________________________________________________________

FAMILY ADAPTATION

Does your child exhibit any challenges related to the home environment? _____Yes _____No

If yes, please elaborate_______________________________________________________________________________

__________________________________________________________________________________________________

How does your child get along with each member of the family?

Father: _____________________________________________________________________________________

Mother: ____________________________________________________________________________________

Siblings: ____________________________________________________________________________________

Have there been any traumatic family events in the course of this child’s development?

__________________________________________________________________________________________________

__________________________________________________________________________________________________


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Have there been any major moves (city to city, country to country)

__________________________________________________________________________________________________

Have there been any specific events or traumas linked with the onset of your child’s difficulties?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Is your marital situation stable and positive at this time? ____________________________________________________

What, if any, stresses are affecting your family at this time? _________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Do either parents have histories of physical or mental health concerns? _________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Are there any religious or cultural considerations we should make in regard to caring for your child in treatment?_______

__________________________________________________________________________________________________

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PREGNANCY (If child is adopted, skip to the adoption section)

What kind of experience was the pregnancy for both parents:

Parent A: __________________________________________________________________________________________

Parent B: __________________________________________________________________________________________

Yes No Comments (please specify)

Were medications taken ____ ___ ____________________________________________________

Were prenatal vitamins taken ____ ___ ____________________________________________________

Prenatal Care Received ____ ___ ____________________________________________________

Were there Complications ____ ___ ____________________________________________________

Accident ____ ___ ____________________________________________________

Health Problems ____ ___ ____________________________________________________

Confinement to bed ____ ___ ____________________________________________________

Other (specify) ____ ___ ____________________________________________________

LABOR AND DELIVERY

Describe your experience during labor and delivery: _______________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Length of Labor _____hrs comments?_________________________________________________

Premature? _____Yes _____No If yes, at what week? __________________________________


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Problems during deliver:

_____None _____Breech Presentation _____Transverse Presentation

_____Placenta Previa _____Abruptio Placenta _____Forceps Used

_____Uterine Rupture _____Prolapsed Cord _____Vacuum

_____Premature membrane rupture _____ Umbilical cord wrapped around neck

_____ Other _________________________________________________________________________________

Caesarean birth _____Yes _____No reason _______________________________________

Birth weight _____lbs _____oz comments:_____________________________________

Cried immediately _____Yes _____No comments: ____________________________________

Length of hospital stay _____ Days _____Months comments:_____________________________________

Medications during labor _____Yes _____No comments: ____________________________________

_____Pitocin _____Cervidil _____Morphine _____Stadol _____Fentanyl

_____Lidocaine _____Epidural _____Nubain _____Other:______________________

Condition at birth:

_____Jaundice _____Poor Color _____Meconium Aspiration _____Seizures

_____Transfusions _____Breathing difficulty _____Cleft Palate _____Cleft Lip

_____Other:_________________________________________________________________________________

Brain Injuries _____Yes _____No comments: _________________________________________________

Did the newborn have immediate physical contact with mother? _____Yes _____No

Comments: _________________________________________________________________________________

Was there a positive bonding experience between newborn and mother? _____Yes _____No

Comments: _________________________________________________________________________________

Describe any separations from mother during first days of life: _____Yes _____No

Comments: _________________________________________________________________________________

Did either parent experience symptoms of post-partum depressions and/or anxiety? _____Yes _____No

If yes, did parent receive a diagnosis and/or treatment for these symptoms? _____Yes _____No

Comments: _________________________________________________________________________________

ADOPTION

Describe the circumstances surrounding the adoption: ______________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

More specifically:

Age when adopted:_____________________________________________________________________

Prior foster homes:_____________________________________________________________________


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Physical appearance:____________________________________________________________________

Response to new home:__________________________________________________________________

Is the child aware of his/her adoption? ____________________________________________________________

INFANCY & TODDLERHOOD

Going back to the first two years of the child’s life, what type of baby was he/she? (feeding, sleeping, activity level)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Yes No Comments

Breastfed _____ _____ _______________________________________

Specific health problems during this period _____ _____ _______________________________________

Thumb sucking/pacifier (until what age) _____ _____ _______________________________________

Feeding problems _____ _____ _______________________________________

Sleeping problems _____ _____ _______________________________________

Colic or “fussy baby” _____ _____ _______________________________________

Prefer certain positions as an infant (describe) _____ _____ _______________________________________

Dislike lying on stomach _____ _____ _______________________________________

Dislike lying on back _____ _____ _______________________________________

Able to self soothe _____ _____ _______________________________________

On a regular schedule _____ _____ _______________________________________

Enjoy bouncing _____ _____ _______________________________________

Become calmed by car rides _____ _____ _______________________________________

Become calmed by infant swings _____ _____ _______________________________________

Crawled at what age? _____ _____ _______________________________________

Toe walker (until what age) _____ _____ _______________________________________

Go through the “terrible twos” _____ _____ _______________________________________

Describe our child’s toddler stage: _____ _____ _______________________________________

CHILDHOOD ILLNESSES/PROBLEMS

Check the items below which have been a problem and provide details:

Age/Comments/Deficits

___ Respiratory Problems ________________________________________________________________________

___ High Fevers ________________________________________________________________________

___ Meningitis ________________________________________________________________________

___ Adenoid problems ________________________________________________________________________


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___ Frequent colds ________________________________________________________________________

___ Strep throat ________________________________________________________________________

___ Allergies If yes, please specify: ___________________________________________________________________

___ Asthma ________________________________________________________________________

___ Bronchitis ________________________________________________________________________

___ Skin Problems ________________________________________________________________________

___ Gastro-Intestinal Problems ________________________________________________________________________

___ Seizures ________________________________________________________________________

___ Epilepsy ________________________________________________________________________

___ Nightmares ________________________________________________________________________

___ Sleep ________________________________________________________________________

___ Bedwetting ________________________________________________________________________

___ Nail Biting ________________________________________________________________________

___ Broken Limbs ________________________________________________________________________

___ Other ________________________________________________________________________

Has he/she ever been hospitalized? Yes _____ No _____

If yes, list reasons: ____________________________________________________________________________

___________________________________________________________________________________________

Has he/she ever had a serious accident/injury? Yes _______ No ________

If yes, list accidents: __________________________________________________________________________

___________________________________________________________________________________________

Are there any other medical illnesses or conditions which have been diagnosed? _________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Is your child in good general health at the present time? _____________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

DEVELOPMENTAL MILESTONES

(Give approximate ages if remembered, or comment on anything unusual)

Enjoy tummy time __________ Hold head up_______________ Rolling Over _______________

Crawl ___________________ Sit alone __________________ Pull self to stand ____________

Walk _____________________ Walk up stairs ______________ Walk down stairs ___________

Stop using Bottle __________ Stop using a pacifier ________ Start eating Baby Foods ________

Start eating Junior Foods _______ Start eating Table Foods ______ Chew Solid Food ________

Drink from a cup _________ Say Words ____________ Name Familiar Objects _________

Use two word combinations _________ Say Sentences _____________


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Was crawling phase brief? Yes ____ No____ Absent? Yes____ No____

Does your child W sit? Often _____ Every once in a while _______ Never ______

Has your child received orthotics? Yes _____ No____

Did child use a walker (rolling plastic seat)? Yes ____ No _____ If yes, how often? ________

Experience hesitancy or delays in learning to go down stairs? Yes ______ No ______

Does your child have any feeding difficulties? Yes ______ No ______

If yes, please explain____________________________________________________________________

_____________________________________________________________________________________

Please list food preferences_____________________________________________________________________

Food dislikes________________________________________________________________________________

Food allergies________________________________________________________________________________

VISUAL DEVELOPMENT

Has your child experienced any problems with his/her eyesight or vision? ________________________________

___________________________________________________________________________________________

Are there any current problems of which you are aware? _____________________________________________

___________________________________________________________________________________________

When was the last time his/her eyesight was tested? _________________________________________________

___________________________________________________________________________________________

AUDITORY DEVELOPMENT

Has your child experienced any problems with his/her hearing? (operations, infections, tubes)

___________________________________________________________________________________________

___________________________________________________________________________________________

Ear Infections? Seldom ____ Sometimes ____ Often _____

Mild ______ Moderate _____ Severe _____

Are there any current hearing problems of which you are aware?

___________________________________________________________________________________________

___________________________________________________________________________________________

When was your child’s hearing last tested?_________________________________________________________


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SPEECH AND LANGUAGE DEVELOPMENT

How would you describe your child’s speech and language development?

Normal ______ Delayed ______ Advanced ______

Did your child babble? _____Yes _____No

Did your child begin speaking in single words, then two, then a sentence? _____Yes _____No

Did your child not talk for a long while, then all of a sudden speak in complete sentences? _____Yes _____No

Do you or others have difficulty understanding what your child says? _____Yes _____No

Does your child understand what is being said to him/her? _____Yes _____No

Does your child understand instructions? _____Yes _____No

How often do you repeat instructions? ___________________________________________________________________

Does your child seem to be aware of a speech difference? _____Yes _____No

First words and at what age: ___________________________________________________________________________

How many words does your child currently use?

___ 0-5 ___ 5-10 ___ 10-20 ___ 20-50 ____ 50-100 ___ >100

How does your child communicate his/her wants and needs? (check all that apply)

___ gestures ___ facial expressions ___ body language ___ pointing

___ eye Gaze ___ sign language ___ vocalizations ___ phrases

___ sentences ___ Augmentative Communication System (specify type) _________________________

Please check any areas of difficulty your child may exhibit:

___chewing ____ swallowing ___ drooling

___transitioning between Foods ____ communicating Needs ____ understanding words

Describe any speech related problems: __________________________________________________________________

__________________________________________________________________________________________________

SENSORY AND MOTOR DEVELOPMENT

Please check any that apply:

____ My child seems to be overly sensitive to sensory experiences more so than most people:

____ auditory ____ tactile ____ visual ____ movement ____ taste ____ smell

____ My child doesn’t seem to react to sensory experiences as readily as most people:


____ My child actively seeks out sensory experiences more so than most people:


____ My child has difficulty differentiating sensory experiences. (ex. Confuse sounds, can’t find objects in drawer or

bag without looking, bumps into things)

Describe: ___________________________________________________________________________________

____ My child has trouble learning new movements.

____ My Child tends to be clumsy and has balance and coordination problems.


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PREVIOUS ASSESSMENTS OR TREATMENT

Has your child had any previous assessments or treatments? _____Yes _____No

Please attach relevant reports.

Assessments Treatments

Yes No Place/Date Yes No Places/Date

Medical ___ ___ _______________________ ____ ____ _____________________

Audiological ___ ___ _______________________ ____ ____ _____________________

ENT ___ ___ _______________________ ____ ____ _____________________

Speech ___ ___ _______________________ ____ ____ _____________________

Educational ___ ___ _______________________ ____ ____ _____________________

Neurological ___ ___ _______________________ ____ ____ _____________________

Neuropsych ___ ___ _______________________ ____ ____ _____________________

Psychological ___ ___ _______________________ ____ ____ _____________________

Occ. Therapy ___ ___ _______________________ ____ ____ _____________________

Opthamologist ___ ___ _______________________ ____ ____ _____________________

Orthopedic ___ ___ _______________________ ____ ____ _____________________

Physical Therapy ___ ___ _______________________ ____ ____ _____________________

Vision ___ ___ _______________________ ____ ____ _____________________

Other ___ ___ _______________________ ____ ____ _____________________

Comments:________________________________________________________________________________________

EDUCATION

School: _________________________________ Grade in School: _______________________________

Teacher’s Name: _________________________ Type of Classroom: _____________________________

How did your child adapt to the first days at school or pre-school:

_____Mostly positive _____Mixed _____Mostly negative

How old was he/she _____ How much time did he/she attend per week? __________

In general, how would you describe your child’s experience/learning at school from Pre-School to the present time?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Please give us more detailed information about any difficulties your child encountered in school beginning with the

earliest experience:

Initial School Adjustment: ____________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


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Preschool/Daycare: __________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Primary (K-Gr.3): ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Junior (Gr. 4-6): ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Intermediate (Gr. 7-8): _______________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

High School (Gr. 9-12) _______________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Has there been remedial help given inside the school system? _____Yes _____No

If yes, describe: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


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GOALS

What are your goals for your child’s program? Please be as specific as possible.

1. ___________________________________________________________________________________________

___________________________________________________________________________________________

__________________________________________________________________________________________

2. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

3. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

4. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

5. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

How did you hear about Milestones? (please check one)

Dr. specifically referred_____________________

Staff at Pediatrician’s office__________________

Other medical professional___________________

Internet__________________________________

Insurance________________________________

Early intervention_________________________

Outside therapist__________________________

Returning client__________________________

Sibling of existing or previous client__________

Friend of the Family_______________________

School__________________________________

Presentation______________________________

Preschool screening________________________

Publication_______________________________

medical history€¦ · 2901 finley rd. ∙ suite 101 ∙ downers grove, il 60515 telephone:...

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