Pediatric History Questionnaire Template - Medstar Georgetown University Hospital
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6Pediatric Occupational Therapy, Physical Therapy, Speech Language Pathology
Pediatric History Questionnaire
This form has important questions that help the therapists understand your child. Please fill in all areas that
you can. Please bring any medical reports you have for our records.
Completed by (Name/relationship to patient): ______________
__Date:_____________
Child’s Name: ______________________
_ Date of Birth: ___________
Age: _____
Address: ______________________________________________________________
Main language used at home: __________ Other languages used: ________________
Email: _______________
____ Secondary Email: ______________________________
Preferred Daytime Phone Number: ( ___)____________
Additional Phone Number
:______________
Why are you coming for an evaluation? What are your main concerns?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Has your child been previously evaluated or treated by an occupational therapist, physical
therapist, or speech language pathologist? Date(s) of Evaluation(s)?
_____________________________________________________________________
_____________________________________________________________________
Please indicate any known adverse/allergic drug and/or food allergies (e.g., penicillin, latex,
gluten):
________________________________________________________________________________
_________
___________________________________________________
Family History
Please indicate who lives at home and/or cares for your child:
Name
Relationship to
Contact Numbers
Medical Diagnoses
Occupation
Child (parent,
sibling, nanny)
Home:________________
Cell:__________________
Home:________________
Cell:__________________
Home:________________
Cell:__________________
Home:________________
Cell:__________________
Home:________________
Cell:__________________
Updated: 2/10/2014
File Location: Shared Drive Active Peds Forms/Questionnaire Forms/History Questionnaire
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