patient questionnaire

After you have received contact from our office indicating that your referral has been accepted, please fill out this form to help us better understand your concerns. Please fill it out with as much detail as possible. Thank you in advance for your time.

name / date

Today's date: *

Month

Day

Year

Child's birthdate: *

Month

Day

Year

Your Name: *

Your relationship to this child: *

Child's first name: *

Child's last name: *

contact information

Street Address:

City:

State:

Zip Code:

Telephone Number:

Alternate Telephone Number:

E-mail Address:

general information

What concerns do you have about your child? *

When were you first concerned about these issues?

Have you previously sought assistance for these concerns?

Concerns

pregnancy, delivery and birth information

Adopted:

Birth mother's age at time of the birth of this child:

Birth father's age at time of the birth of this child:

Pregnancies prior to this baby?

Number pregnancies

Any miscarriages prior to this pregnancy?

Number miscarriages

Any complications during pregnancy or delivery of this child?

Complications

Did the mother require any medications during pregnancy?

Medications

Did the mother smoke during pregnancy?

Did the mother drink during pregnancy?

Did the mother use recreational drugs during pregnancy?

Was this child full-term or premature?

Premature

Was the delivery vaginal or C-section?

C-section

Birth weight:

Birth length:

Birth head circumference:

APGAR scores (if known):

Did the baby have problems after delivery?

Problems

medical background

Previously diagnosed medical conditions:

current medications

Medication:

Dose:

How often?

Medication:

Dose:

How often?

Medication:

Dose:

How often?

Has your child had any hospitalizations or surgeries?

Hospitalizations

family/homelife information

Birth Mother's Name:

Birth Mother's Occupation:

Birth Father's Name:

Birth Father's Occupation:

Other Guardians:

Current marital status of guardians:

Who has custody of this child currently?

Who shares in the care of this child?

Who lives in the home with this child?

Sibling's names and ages:

Do any of the child's siblings have any developmental delays or health concerns?

Have there been any recent changes in the child's family situation? For example: Divorce, separation, move, death, illness, etc.

Are there any medical problems that run in the birth mother's side of the family?

Are there any medical problems that run in the birth father's side of the family?

Has your child attended any special educational programs or other special programs? If yes, please list current and past programs and dates attended:

developmental history

At what age did your child ...?

Roll over:

Crawl:

Walk:

Pull up to stand:

Say first word other than mama/dada:

Put two words together:

Approximately how many words does your child have currently?

Is he/she more difficult to understand than other children of the same age?

Has your child attended any special education programs or other special programs?

Past programs

* Please bring any prior testing or school reports with your visit.

What opportunities does your child have to interact with children of the same age?

do you have any concerns about any of the following:

Does your child act differently than other children his/her age?

Act differently

Do you feel that your child has lost any skills?

Skills

How your child understands what you say?

Understands

How your child uses words and sentences to communicate?

Words/Sentences

How your child uses his/her hands and fingers?

Hands

How your child uses his/her arms and legs?

Arms/Legs

Does your child have any feeding difficulties or need a special diet?

Diet