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Birth History: _________________________________________________________________________
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Describe the problem for which you seek occupational/physical/speech therapy for your child.
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What are your personal goals for your child in occupational/physical/speech therapy?
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Is your child receiving services from anyone else for this problem?
_____________________________________________________________________________________
What medications is your child taking? (prescription and non-prescription)
_____________________________________________________________________________________
Has your child had any medical tests?(MRI, X-ray, EMG, Vision, Hearing, Swallow, etc.)
_____________________________________________________________________________________
Medical History:
Allergies (latex, food, meds, environmental):________________________________________________
Please check if your child has had any of the following problems:
□ Heart Condition
□ Pacemaker
□ Circulatory Problems
□ Diabetes
□ Hypertension
□ Stroke
□ Cancer
□ Neurological Disease
□ Lung Condition
□ Psychological
□ Head Injury
□ Seizures/Epilepsy
□ Fractures
□ Neck Injury
□ Back Injury
□ Hearing Loss
□ Vision Loss
□ Artificial Joint
□ Infectious Disease
□ Osteoporosis
□ Arthritis
□ Surgery
□ Other
Brief history of surgeries and categories checked:
_____________________________________________________________________________________
_____________________________________________________________________________________
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Within the past year, has your child had any of the following symptoms? (Check all that apply)
□ Chest pain
□ Heart palpitations
□ Persistent or productive cough
□ Hoarseness
□ Shortness of breath
□ Dizziness or blackouts
□ Weakness in arms or legs
□ Other:___________________
□ Falling
□ Difficulty walking
□ Joint pain or swelling
□ Pain at night
□ Difficulty sleeping
□ Loss of appetite
□ Nausea/Vomiting
□ Difficulty swallowing
□ Bowel problems
□ Weight loss or gain
□ Urinary problems
□ Fever/Chills/Sweats
□ Headaches
□ Loss of balance
Brief history of symptoms checked:
_____________________________________________________________________________________
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Please describe any other medical history or information related to condition.
_____________________________________________________________________________________
_____________________________________________________________________________________
Daily Routine (wake up time, meal times, school, daycare, bed time):
_____________________________________________________________________________________
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