Fillable Pediatric Case History Reason for Todays visit Referred (Sacred Heart University)

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Pediatric Case History Reason for Todays visit Referred (Sacred Heart University)

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The Pediatric Case History Reason for Todays visit Referred (Sacred Heart University) form is 2 pages long and contains:

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  • 68 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Sacred Heart University

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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
Pediatric Case History
Name: Date of Birth: / / Today's Date: / /
Reason for Today’s visit
Referred by
Child lives with: both parents Mother Father other
Names and ages of any other children at home:
Name and Address of Child's School, Preschool or Child Care Setting
GENERAL MEDICAL
1. Do you have any medical concerns about your child? YES
NO
If yes, briefly explain:
2. Please check if your
child has had any of the following:
Briefly explain any you checked:
3. Please list any prescription or over-the-counter medications your child is taking and for
what reason(s):
4. Has your child ever experienced head trauma? YES NO
5. Has your child ever had surgery on his/her ear(s), nose, or throat? YES NO
HEARING (Please fill in the blanks or check where appropriate)
1. Do you have any concerns about your child’s hearing? YES NO
If yes, briefly explain:
2. Does anyone in your family have hearing loss (immediate and extended family) that began before the age
of 30? YES NO If yes, who?
4. Does your child consistently respond to your voice? YES NO
5. Does your child respond to loud noises? YES NO
6. When sound is present or someone is speaking, does your child search to find where the sound is coming
from? YES NO
7. Does your child respond to sounds from other rooms?
YES NO
8. Does your child enjoy listening to music? YES NO
9. Has your child’s hearing ever been tested? YES NO
If yes, please list by whom, when and results
10. Does your child wear hearing aid(s)? YES NO
If yes, when was your child first fit?
YES NO
11. Does your ch
ild rec
eive p
referen
tial cla
ssroom seating?
Pregnancy And Birth History (please check YES or NO)
1. Was the pre
gnancy abnormal in any way? YES NO
2. Was the delivery abnormal in any way? YES NO
3. Was the delivery premature? YES NO
4. Did the mother have any illness during the pregnancy? YES NO
5. Did the mother take any medication during the pregnancy? YES NO
6. After birth, did your child have:
Breathing difficulties?
NO
Require an incubator?
NO
Any head, neck or ear abnormalities?
NO
Feeding problems?
NO
Surgery?
NO
Any infections requiring medication?
NO
Treatment for jaundice (yellow coloration of the skin)?
NO
If yes to any of the above, briefly explain:
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Pediatric Case History Reason for Todays visit Referred (Sacred Heart University)

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Completed 25 August 2020

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