Pediatric Case History Form printable pdf download

PEDIATRIC CASE HISTORY FORM

Child’s Name: __________________________ DOB _________________ Age ________

Chief Complaint: _______________________________________________________

PRIMARY PHYSICIAN: ________________________________________________

Hearing History

YES

1. Do you have concerns about your child’s hearing?

If yes, briefly explain ___________________________________________________________

2. Does anyone in the child’s immediate or extended family (blood relation) have hearing loss

that began before the age of 30? Relation ________

3. Does your child wear hearing aids or use an auditory trainer? (Circle one, if yes)

Pregnancy and Birth History

1. Was the pregnancy/delivery of this child abnormal in any way?

If yes, please explain ____________________________________________________________

2. Did your child stay in the NICU for any duration after birth?

3. Was there a history of drug use or STD during pregnancy?

If yes, please explain ____________________________________________________________

Speech/Language History

1. Do you have any concerns about your child’s speech and language?

If yes, please explain ____________________________________________________________

2. Is your child currently receiving speech therapy?

Medical History

1. Do you have any medical concerns about your child?

If yes, briefly explain ____________________________________________________________

2. Please check if your child has had any of the following:

Ear infections _____

Meningitis _____

Seizures _____

Ear Surgery _____

Measles _____

Kidney Problems _____

Hospitalization _____

Mumps _____

Vision Problems _____

Head Trauma/Injury _____

Chicken Pox _____

Allergies _____

Noise exposure (e.g. farm equipment, loud music) _____

Asthma _____

3. Is your child in any pain? If so, rate from 1 to 10 (10 being most severe) _____

4. Is your child on any medications? If so, please list _________________________________

5. Were you taking any medications while pregnant? If so, please list:

_____________________________________________________________________________

Additional History

1. Do you have any other concerns about your child?

If yes, briefly explain ___________________________________________________________

2. Does your child:

Play/interact well with other children?

Have attention/concentration difficulties?

Receive any special education services?

Name of School: _______________________________________________________________

Grade your Child is currently in: __________

_______________________________

__________________

_____________

Parent or Guardian’s Signature

Relationship

Date

Pediatric Case History Form

Related Articles

Related forms

Related Categories