The child lives with:

Name Age Occupation/Work

MATERNAL HISTORY:
1. Lifestyle before pregnancy
a. Sedentary (Not active)
b. Active

2. Did you work before you got pregnant?

a. Yes
i. How many days in a week?
ii. How many hours do you work/Schedule?
iii. How difficult is your job/How heavy is your workload?
b. No

3. Mother’s vices prior to pregnancy: __________________________________________

4. Mother’s age during pregnancy: _________________ Spouse: __________________
5. Do you take any vitamins prior to your pregnancy? _________________
6. What do you usually eat during your pregnancy? __________________
7. Do you encounter fertility problems or other problems during pregnancy? YES NO
(Specify): _______________________________________________________________

PRENATAL
1. How did you know you were pregnant?
______________________________________
2. How did you confirm you were pregnant?
_____________________________________
3. Was the pregnancy planned? YES NO
4. Did you want to get pregnant at this time? YES NO
5. Did you use any contraceptives? If yes, what contraceptive?
6. Did you go to the doctor to have a check-up?
a. YES
i. How often? __________
ii. Medication given and for what (if applicable) ____________________
iii. What procedures were done (US, checking of heartbeat, correct
position of the client)
________________________________________________________
__________________
b. NO
 7. Did you drink any vitamins during your pregnancy?
_____________________________________
8. What do you normally eat during pregnancy? _____________
9. Did you feel any morning sickness? If yes, what are your symptoms?_____________
10. Did you have any cravings? ______ If yes, what are these foods? _____________
11. Lifestyle during pregnancy? SEDENTARY/NOT ACTIVE OR ACTIVE
12. Were you working while pregnant? _____________
13. Did you have any vices during pregnancy? _____________
14. Did you have any illness before getting pregnant? _____________

PERINATAL
Medications during pregnancy: ________________________________________________
Way of delivery: Normal / Caesarian / Others: _________
Gestational age: Pre-term: _____ / Full-term: _____ / Post-term: _____
Hospital: _________________________________________________________________
How was the child after birth: _________________________________________________

POSTNATAL
How many pregnancies have you had? ________
How many pregnancies have reached full-term? ________
How many pregnancies are premature? ________
How many abortions/miscarriages have you had? _________
Are all your children alive? ________
Saan po siya pinanganak? _________________
Kumpleto po ba ang vaccinations/immunizations? Ano-ano po ito?
_________________________________________________________________________
_______________________________________________________________.

Kailan po ang unang check-up sa DevPed? ________

Saan po siya nagpa-check-up? __________________
Kamusta po ang check-up sa DevPed?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________.

Kailan po nadiagnose? _______________

Nakapagtherapy o OT na po ba dati? ______________________

Kung Oo, Sino po ang nagrefer sa OT? ________________________

Pang ilan na OT niya na po ngayon? _______________________

Ano po ang tinarget ng OT before?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
__________________________.

Na-ospital na po ba dati? Kung Oo, bakit po?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
______________________________. Saang ospital po? ________________________

Kamusta po siya sa school ngayon? Ano po ang sinasabi ni teacher?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Ano po ang mga nakasanayan niyang gawin o habits (example: mahillig mag-ngatngat ng
kuko kapag kinakabahan)? Nakaka-apekto po ba ito sa mga gawain niya pang-araw araw?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Kamusta po kapag naghuhugas ng kamay? Kaya po ba niya na mag-isa o may katulong?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.
Kamusta po kapag naghihilamos? Kaya po ba niya na mag-isa o may katulong?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.

Marunong po ba maggupit ng kuko? Kaya po ba niya na mag-isa o may katulong?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.

Kamusta po kapag nagpapagupit ng buhok?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.

Marunong po ba maglinis ng tenga? Kaya po ba niya na mag-isa o may katulong?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.

Kamusta po ang knowledge niya sa Shapes? Kaya po ba niyang mag-identify ng iba’t ibang
shapes ng mag-isa?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Kamusta po ang knowledge niya sa Body parts? Kaya po ba niyang mag-identify ng mga
parte ng katawan ng mag-isa?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Meron pa po ba kayong gustong ibahagi na hindi niyo pa po nababanggit?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________