Pediatric Health Questionnaire

  • Pediatric Health Questionnaire

    Clough Family Center for Rehabilitative and Sport Therapies

    Welcome to Emerson Hospital's outpatient services! Please fill this form to the best of your ability, thank you.

     

    Section 1 (Medical and Social History)

  • Parent/Guardian Information

  • Format: (000) 000-0000.

  • Patient Information

  •  / /

  • Family History

  • Languages

  • Are there languages other than English spoken at home/school?
  • Would you like an interpreter?

  • Educational and Social History

  • Does your child attend daycare or school?
  • Does your child have an IEP (Individual Education Plan) and receive services at their school?
  • If no, did your child have an IEP in the past?

  • Medical History

  •  / /
  • Does your child see other doctors/specialists (ex: neurology, GI, orthopedics)?
  • Any history of serious illnesses, diseases, broken bones, or surgeries?
  • Any history of seizures?
  • Please check all that apply to your child (past/present):

  • Adaptive Equipment

  • Does your child have or need adaptive equipment (wheelchair, utensils, communication device, etc)?

  • Activities

  • Section 2 (Developmental History)

  • Pregnancy and Birth History

  • Any complications for mother or baby during pregnancy?
  • Any complications during delivery (need for oxygen, low APGAR scores etc.)?
  • NICU stay?
  • Any concerns with your child’s weight gain or growth?
  • Failure to thrive?
  • Does/did your child have torticollis?
  • Does/did your child have reflux?

  • Developmental History

  • To the best of your ability, list the age your child did the following:

  • Any concerns with regression in any areas (speech/language, gross motor skills)?

  • Section 3 (Hearing/Communication)

  • Has your child had tubes placed in their ears?
  •  / /
  • Results:
  • Has your child received a formal diagnosis by a medical professional? (e.g. Learning Disability, Autism Spectrum Disorder, Down Syndrome, etc.)
  • Do you have concerns about your child’s communication and/or social skills?
  • Does your child have any history of vision challenges?

  • Section 4 (Sensory Motor Skills)

  • Please check all that apply:

  • Section 5 (Feeding)

  • Early Feeding History

  • Any concerns with dehydration (past/present)?
  • Any concerns with constipation (past/present)?
  • Any concerns with sleep (past/present)?
  • Was your child breast-fed?
  • Did your child latch easily for breastfeeding?
  • Was your child bottle fed?
  • History of dependence on supplemental nutrition?
  • Did your child use a pacifier?
  • Did your child mouth toys as an infant?
  • Any problems with solid food introduction?
  • Any problems with the below (current or past)?
  • History of (check all that apply):
  • History of (check all that apply):

  • Current Feeding Status

  • How is your child currently being fed? Check all that apply.
  • Does your child show signs of hunger?
  • Feeding environment:
  • Are feeding times stressful?
  • Currently drinks from (check all that apply):
  • Currently eats with (check all that apply):
  • Does your child currently:
  • Any other behaviors of concern? Check all that may apply:

  • Historically, does your child consume adequate amount and variety of:

  • Liquids
  • Fruits
  • Vegetables
  • Grains
  • Dairy
  • Meats

  • What does your child eat on a “typical” day? List specific foods and times.

  • Should be Empty: