Family And Medical History Form Page 3
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1
2
3
4
5
67
Very low tone
8
Brain hemorrhage
9
Anemia and/or transfusions
Which/how many times?
10
Jaundice (yellow)
How much/how treated?
11
Had bruising
12
Rh incompatibility problems
13
Infections
14
Congenital birth defects
15
Aspiration (meconium or fluid)
Which/how treated?
16
Respiratory distress signs or syndrome
17
Needed ventilation
What type/how long?
18
Choking or vomiting episodes
19
Tube feedings
20
Needed medications
PART 3: MEDICAL HISTORY OF CHILD
Please mark if you child has had any of the following.
ITEM
NO
YES
DESCRIPTION
EXPLANATION
1
Frequent Colds/Respiratory Illness
2
Frequent Strep throat/sore throat
3
Frequent Ear Infections (tubes)
4
Birth defect/genetic disorder
5
Lung condition/respiratory disorder
6
Allergies or asthma
7
Heart condition
8
Anemia/blood disorder
9
Kidney/Renal disorder
10
Urinary problems/infections
11
Hormonal problem
12
Muscle disorder/muscle problem
13
Joint or bone problems
14
Fractured bones
15
Skin disorder/skin problems (eczema)
16
Visual disorder/vision problems
17
Eye infections
18
Neurological disorder
19
Seizures or convulsions
20
Stomach disorder/stomach pain
21
Vomiting/digestion problems
22
Failure to gain weight/feeding problems
23
Constipation/diarrhea problems
24
Dehydration episodes
25
Hearing Loss/Ear disorder
Bacharach Institute for Rehabilitation, 61 W Jimmie Leeds Road, Pomona, NJ, 08234
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