Pediatric History Form

Pediatric History

Child's First Name(Required)

Child's Last Name(Required)

Parent/Guardian Email(Required)

Biological Sex(Required)

Date of Birth(Required)

Child is

Adopted at what age?

If international adoption, explain setting of pre-adoption history.

How long in foster care?

Please give a brief explanation of known trauma history (abuse, neglect, sexual trauma, etc.):

If this information is better explained via phone or email, please let us know. It’s imperative that your therapist be informed PRIOR to the evaluation.

How did you hear about Pediatric Connections?(Required)

If applicable, who referred you to Pediatric Connections?

Why were you referred?

Family Information

Child lives with:(Required)

Please list all persons living in the home with names and relationship to client – Including ages of all children in the home.

Primary Parent Occupation

Please specify mother or father

Secondary Parent's Occupation

Please specify mother or father as applicable

Medical History

Was client born premature?(Required)

Gestational week

Describe birth history, including complications:(Required)

If client is under 18

Medical conditions/allergies(Required)

Precautions(Required)

Food/nut allergies, seizures, reflux, etc

Diagnosis (as given by MD)

Medications

Please include all medications your child is taking

Hearing/Vision Concerns

Communication

Other Therapies

Please select any other therapies your child is currently receiving or has received in the past.

School/Home/Community

School Name

School District

Grade

Services recieved at school:

Speech

Occupational Therapy

Physical Therapy

Specialized Instruction

Counseling

Other

None

Is client having difficulties at school? Please list areas of concern.

Is client having difficulties at home? Please list areas of concern.

Is client having difficulties within the community (stores, unfamiliar place, etc)? Please list concerns.

Please place a check by those characteristics you observe with your child. Please add comments or additional concerns:

Select items of concern for each category. Depending on your child’s age, some items may not be age appropriate yet.

Muscle Tone(Required)

Muscle Tone Comments

Babinski(Required)

Babinski Comments

Foot Tendon Guard(Required)

Foot Tendon Guard Comments

Legs Cross Flexion Extension(Required)

Difficulty coordinating legs to ride a bicycle

Hesitant when descending/climbing stairs

Hyperactivity

Poor coordination across the body mid-line/poor ability to cross crawl

Postural problems in general

None noted

Legs Cross Flexion Extension Comments

ATNR(Required)

ATNR Comments

Trunk Extension(Required)

Posture tends to bend forward or backwards; does not seem to have mid-line

Tendency to toe walk

Difficulty pushing up on toes and coming back down as when needing to reach something that is high up

Over focused on details, missing the big picture; “can’t see the elephant in the room”

Emotional or irrational issues; talks without making emotional connections

Limited imagination

Timing of jumping is not there

Leans against external supports when sitting or standing

None noted

Trunk Extension Comments

Hand Grasp(Required)

Hand Grasp comments

Hands Supporting(Required)

Lack of arm, hand, eye coordination

Lack of body and space awareness/boundaries

Poor safety awareness

Poor social boundaries (aggressive, standoffish, isolated, easily becoming a victim, bully or being bullied)

Frequent injuries with falls (does not put hands out to protect self)

None noted

Hand Supporting Comments

Hands Pulling(Required)

Hands Pulling Comments

Babkin(Required)

Associated oral reactions with hand utilization (i.e. tongue movements, lip movements or tightening of the lips. Tongue moves when cutting with scissors)

Biting/chewing on clothing/objects

Clenched fists

Eating challenges

Nail biting

Digestive issues

Difficulty blowing nose to clear

None noted

Babkin Comments

Moro(Required)

Moro Comments

Fear Paralysis(Required)

Fear Paralysis Comments

Spinal Perez(Required)

Spinal Perez Comments

TLR(Required)

TLR Comments

Landau(Required)

Poor muscle tone

Difficulty concentrating

Clumsy in movements

Stands with locked knees

Hard to understand new things

None noted

Landau Comments

Bauer Crawling(Required)

Asymmetrical gait pattern (i.e. arms/legs do not swing in a cross body pattern)

Poor orientation in space

Poorly developed perspective, vision

Slow study pace with academics

None noted

Bauer Crawling Comments

Spinal Galant(Required)

Spinal Galant Comments

STNR(Required)

STNR Comments

Flying and Landing(Required)

Phobias of heights

Gravitational insecurity: does not like their feet to leave the ground

Unable to jump effectively

Impulsive jumping; jump all the time

Challenged to judge height and depth

Lacks control in dangerous situations

None noted

Flying and Landing Comments

Goals

It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities we can address first:

Goal #1(Required)

Goal #2

Goal #3

Goal #4

Your Child's Strenghts(Required)

Your Child's Challenges(Required)

Any other comments/concerns not addressed above?

FAX

Pediatric History Form

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(913) 257-5808