Health History Questionnaire

Early Intervention (0 to 3 years)

Please allow us to develop the best plan to address your child’s needs by completing the following questionnaire.

Child’s Name: Click here to enter text.

Parent / Caregiver’s Name: Click here to enter text.

Date of Birth: Click here to enter text.

Pediatrician: Click here to enter text.

Please List all your child’s Medical Diagnoses:

1. Click here to enter text.

2. Click here to enter text.

Other: Click here to enter text.

Please List all your child’s Medications & Dosages:

1. Click here to enter text.

2. Click here to enter text.

Other: Click here to enter text.

Family History

☐ Mental Health Disorder

☐ Vision Impairment

☐ Use of Drugs or Alcohol during Pregnancy

☐ Other: Click here to enter text.

Pregnancy & Birth History

Were there any complications during pregnancy?	☐ Yes	☐ No

If yes, please give a brief description: Click here to enter text.

Was the pregnancy full term?	☐ Yes	☐ No

If not, how many weeks? ________

Birth Weight ________

Was the birth	☐ Vaginal	☐ C-section	Apgar Scores Click here to enter text.

Please describe any complications during delivery: Click here to enter text.

Is there any History of Post natal Depression? ☐ Yes	☐ No	Or Domestic Violence?	☐ Yes ☐ No

Medical & Surgical History

Please List all Hospitalizations and surgeries with dates (including NICU stay): Click here to enter text.

Was your child on the any of the following?

☐ Vent:

☐ C-Pap:

☐ Oxygen by nasal cannula:

From _________

From _________

From _________

to _________

to _________

to _________

Has your Child ever had a tracheostomy?	☐ Yes	☐ No

From _________

to _________

Medical & Surgical History (cont.)

Does Your Child have a history of (check all that apply):

1.	☐ Reflux

2.	☐ Feeding difficulties:	☐ Resolved	☐Ongoing	Consistency of food _______	Tube fed: ☐ Yes ☐ No

☐ Has your child has a Swallow Study?	☐ Yes ☐ No

3.	☐ Difficulty sleeping:	Hours of sleep per night _____	Hours of sleep during the day _____

4.	☐ Seizures:	Controlled by: ____________________________________________________________

5.	☐ Fractures:	Date & Location: __________________________________________________________

6.	☐ Pain:	When & Where do you suspect pain: _________________________________________

7.	☐ Difficulty Hearing	Date of last hearing screen: _____________	Result: __________________________

8.	☐ Vision problems	Date of last vision screen: ______________	Result: __________________________

9.	☐ Ear Infections:	How many in the past 6 months? ____________________________________________

10.	☐ Allergies: _________________________________________________________________________________

Is your child being followed by any of these doctors? If yes when was your last visit?

☐	Cardiology:	☐	Geneticist:	☐	Orthopedic:
☐	Endocrinology:	☐	Neurology:	☐	Physiatrist:
☐	ENT:	☐	NICU MD:	☐	Pulmonologist:
☐	Gastroenterologist:	☐	Ophthalmology:	☐	Other:

Developmental Milestones

At what age did your child first:

Roll over:	Walk:	Babble:
Crawl:	Sit independently:	First word:
Ate table food:

Direct Services History

Has your child received services from any of the following Specialists? If so, Please indicate when services ended.

☐	Developmental Spec.:	☐	Physical Therapist	☐	Counselor:
☐	Occupational Therapist:	☐	Speech Therapist:	☐	Other:

Additional Notes / Comments

Click here to enter text.