Family And Medical History Form (Page 4 of 6) in pdf

Family And Medical History Form Page 4

Significant accidents

Head injuries or concussions

Ingestion of toxins, poisons, foreign objects

Major medical procedures (detail below)

Chronic medications (for what? when?)

Any major childhood illness (pox, croup,

measles, mumps, meningitis etc)

HOSPITALIZATIONS AND/OR SURGERIES:

List the dates of any hospitalizations your child has had and the reason. List the dates of any surgeries your child

has had and the reasons.

3. ______________________________________

4. ______________________________________

PRESENT HEALTH STATUS:

Most recent Height =

Weight =

Date:

Are vaccinations up to date? _______________ If not, why? __________________________________________

Please note any illnesses for which your child is currently being treated, including their Current Medications:

PART 4: DEVELOPMENTAL HISTORY

We would like to have information about your child’s developmental milestones. Indicate the age when your child

first did each of the following INDEPENDENTLY. If you can not recall/find a specific age, please mark whether you

believe your child accomplished the milestone early, on time or late. If your child has not yet achieved the

milestone, write NA in the age column. Please also rate your estimation of the quality of your child’s skills.

MILESTONE

AGE

EARLY

ON TIME

LATE

GOOD/FAIR

POOR

Smiled

Held head up

Rolled over

Reached for an object actively

Transferred object between hands

Sat unsupported

Crawled

Stood alone

Walked by self

Said first words

Threw objects actively

Ran by self

Followed simple 1 step directions

Said 2-3 phrases

Ate unaided with a spoon/fork

Dressed self

Rode bicycle without training wheels

Bacharach Institute for Rehabilitation, 61 W Jimmie Leeds Road, Pomona, NJ, 08234

Family And Medical History Form Page 4

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