Patient History, Tests and Measures:

Background information

Was your child born at full term?

Did you have any complications during the pregnancy?

How much did your child weigh when they were born?

Did your child have any medical issues, complications after birth? (need for O2, tube feeding, NICU, respiratory
difficulties, g tube placement, etc.)

Has your child had any surgeries or hospitalizations? How many, when and for what reasons?

Is your child currently taking any medications? What are there names?

Does your child have any allergies to food, medications, latex, etc.?

Has your child received any type of therapy before? (PT, OT, ST) If so where and how long?

Has your child been diagnosed with any other disease conditions? (ie. Autism, heart disease, developmental delay,
brain injury, respiratory illness, asthma, seizures, chronic ear conditions, diabetes, etc.)

Does your child have any special equipment that they use? (Walker, wheelchair, stander, O2,etc.)

Self Care:

Is your child toilet trained? Do they wear diapers?

Does your child need any assistance with dressing?

Does your child need any assistance with brushing their teeth, brushing, their hair, etc.

Feeding/swallowing:

Is your child able to eat a regular diet, do they have restrictions, are they tube fed?

Has your child ever had to receive their food through a tube?

Did your child nurse? How long, why did it stop?

Did your child take to a bottle? How long? Why did it stop?

Has your child ever had a swallow study? What were the results?

Developmental History
When were they able to:

Lift their head

Roll over to their stomach

Sit up when placed

Crawl on belly

Crawl on hands and knees

Sit Independently

Pull to stand

Walk independently

Pain Levels:

During day:

At night

Positions:

Laying on back

Laying on side

In sitting

Standing

Walking

Running

Jumping:

MMT RIGHT LEFT

Shoulder Flex

Shoulder ABD

Elbow Flexion

Elbow Extension

Wrist Flexion

Wrist Extension

Hip Flexion
Hip Abduction

Hip Adduction

Knee Flexion

Knee Extension

Dorsiflexion

Plantarflexion

ROM RIGHT LEFT

Shoulder Flex

Shoulder ABD

Elbow Flexion

Elbow Extension

Wrist Flexion

Wrist Extension

Hip Flexion

Hip Abduction

Hip Adduction

Knee Flexion

Knee Extension

Dorsiflexion

Plantarflexion