Pediatric History Questionnaire Template - Medstar Georgetown University Hospital (Page 5 of 6) in pdf

Pediatric History Questionnaire Template - Medstar Georgetown University Hospital Page 5

Does your child have difficulty falling asleep?  Yes  No

On average, how many times does your child wake up during the night?___________

Does your child self-feed?  Finger  Utensils  Other_______________________

Does your child have any repetitive behaviors? (Hand flapping, rocking, lining up toys)

_____________________________________________________________________

Is your child bothered by certain sensations / feelings?

 Noises Textures, clothing, or touch  Movements  Lights

Please Specify: _________________________________________________________

Please add any other information we should know: _____________________________

______________________________________________________________________

________________________________________________________________________________

THIS QUESTIONNAIRE WAS REVIEWED BY:

Therapist’s Signature: _________________________

Date: ________________

Updated: 2/10/2014

File Location: Shared Drive Active Peds Forms/Questionnaire Forms/History Questionnaire

Pediatric History Questionnaire Template - Medstar Georgetown University Hospital Page 5