INITIAL EVALUATION SUBJECTIVE HISTORY WORKSHEET

Pediatric (page 1)
Patient Name: _____________________________________________ Date of Birth:____________ Date of Eval: ____________

SUBJECTIVE
Why are you seeking treatment for your child? ____________________________________________________________________________
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Has your child had any prior treatment and/or diagnostic testing for this condition? □ Yes □ No
If Yes: □ X-rays □ MRI □ EMG/Nerve Conduction Test
Other:__________________________________________________________________________________________________________________
If Yes, please explain: __________________________________________________________________________________________________
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Date of next Doctor’s appointment: _________________________

THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Subjective History: ______________________________________________________________________________________________________
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CURRENT COMPLAINTS
What are your main concerns regarding your child?
□ Fine Motor (i.e., handwriting, buttoning) □ Mobility □ Feeding □ Behavior □ Other: ____________________________
□ Gross Motor (i.e., walking, kicking a ball □ Speech □ Language □ Other: ____________________________

THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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PREGNANCY AND BIRTH HISTORY

Were there any complications during pregnancy? □ Yes □ No Comments: ______________________________________
Was the pregnancy full term? □ Yes □ No Comments: ____________________________________________________
Were any drugs or medications taken during pregnancy? □ Yes □ No Comments: ___________________________________
Was labor and delivery normal? □ Yes □ No Comments: ____________________________________________________
Please list birth weight and length: _______________________________________________________________________________
THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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 INITIAL EVALUATION SUBJECTIVE HISTORY WORKSHEET
Pediatric (page 2)
Patient Name: ________________________________________________ Date of Birth:____________ Date of Eval: ____________

GROWTH AND DEVELOPMENT

At what age did your child:
□ Roll over from stomach to back? _________ □ Roll over from back to stomach? _____________________
□ Sit Independently?_____________________ □ Crawl? __________________________________________
□ Walk holding onto furniture? ___________ □ Walk independently? ______________________________
□ Speak first word? _____________________ □ Speak in 2 word sentences? _________________________
□ Drink from cup? _______________________ □ Use a spoon? ____________________________________
□ Dress independently?___________________ □ Toilet train? _____________________________________
Please describe your child:
□ Mostly Quiet □ Tires Easily □ Talks Constantly □ Clumsy □ Happy
□ Impulsive □ Overly Active □ Overreacts Frequently □ Shy □ Restless
□ Craves Touch □ Impulsive □ Gets Frustrated Easily □ Stubborn □ Has Temper Tantrums
□ Difficulty Separating □ Has Nervous Habits □ Has Unusual Fears □ Avoids Touch □ Has Poor Attention Span
□ Difficulty Learning New Tasks □ Other:___________________________________________________
THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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PREVIOUS MEDICAL HISTORY

How would you classify your child’s general health? □ Good □ Fair □ Poor
Please check ALL that apply:
□ Allergies □ Encephalitis □ Multiple Sclerosis □ Rheumatic Fever
□ Asthma/Breathing Difficulties □ Enlarged Glands □ Nausea/Vomiting □ Ringing of the Ears
□ Bronchitis □ Fever □ Night Pain □ Seizures/Epilepsy
□ Cancer □ Head Injury □ Osteoarthritis □ Sinusitis
□ Chest Pain/Angina □ Headaches □ Osteoporosis □ Smoking History
□ Chicken Pox □ Heart Disease □ Pacemaker □ Stroke/TIA
□ Chronic Colds □ High Blood Pressure □ Parkinson’s Disease □ Surgeries
□ Chronic Laryngitis □ Hypoglycemia □ Physical Abnormalities □ Thyroid Disease
□ Congenital Defects □ Measles □ Pneumonia □ Tonsillitis
□ Depression □ Meningitis □ Polio □ Tuberculosis
□ Diabetes: Type I or II □ Metal Implants □ Pregnancy (Currently) □ Whooping Cough
□ Dizziness/Fainting □ Mumps □ Rheumatoid Arthritis
Is there any other information regarding your child’s medical history that we should know about? __________________________
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Does your child have any of the following? If Yes, please explain in the space provided:
□ Earache/Ear Infection Describe: ______________________________________________________________________
□ Hearing Difficulties If Yes, Aided? ___________________________________________________________________
□ PE Ear Tubes Inserted Describe: ______________________________________________________________________
□ Vision Problems If Yes, Treatment? _______________________________________________________________
Have you ever purchased or rented Durable Medical Equipment, Orthotics, Prosthetics, or Supplies?
□ Yes □ No Explain: ______________________________________________________________________________________
THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Please List Previous Medical History or Co-Morbidities that May Impact Rate of Recovery: _____________________________________
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 INITIAL EVALUATION SUBJECTIVE HISTORY WORKSHEET
Pediatric (page 3)
Patient Name: ________________________________________________ Date of Birth:____________ Date of Eval: ____________
MEDICAL PRECAUTIONS/CONTRAINDICATIONS
Are there any factors that may complicate your child’s ability to participate in therapy? □ Yes □ No
If Yes, please explain: _______________________________________________________________________________________
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Does your child have food allergies? □ Yes □ No
If Yes, please list: ___________________________________________________________________________________________
Does your child have any movement restrictions? □ Yes □ No
If Yes, please list: ___________________________________________________________________________________________

THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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MEDICATIONS
Please list all of the medications [with specific NAME, DOSAGE, FREQUENCY, and ROUTE (ie: by mouth)] that you are currently taking [including
over-the-counter, prescriptions, herbals, and vitamins/mineral(s)]: ________________________________________________________________
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COMMUNICATION HISTORY
Please describe any communication difficulties: ___________________________________________________________________
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When was the problem first noticed? _____________________________________________________________________________
Other language(s) besides English spoken in the home: ______________________________________________________________

THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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SOCIAL HISTORY/INTERESTS/LIVING ENVIRONMENT

Father’s Name: _______________________________________________ Age: _____ Occupation: _________________________
Mother’s Name: ______________________________________________ Age: _____ Occupation: _________________________
Is he/she adopted? □ Yes □ No If Yes, at what age? ______
Parent’s Marital Status □ Married □ Living Together □ Separated □ Divorced □ Remarried
Who lives in the house with this child? ___________________________________________________________________________

THERAPIST USE ONLY: I have reviewed the information provided and: Information is complete Additional comments below
Other Related Information: ______________________________________________________________________________________________
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 INITIAL EVALUATION SUBJECTIVE HISTORY WORKSHEET
Pediatric (page 4)
Patient Name: _______________________________________________ Date of Birth: _____________Date of Eval: ____________

EDUCATIONAL HISTORY
Does your child attend school? □ Yes □ No Has your child ever repeated a grade? □ Yes □ No
If Yes, where?_______________________________________ If Yes, what grade(s)?________________________________
What grade is he/she in? _____________________________

Does your child have Special Education or Therapy services in school? □ Yes □ No
If Yes, what services? □ Physical Therapy □ Occupational Therapy □ Speech Therapy
How often? ________________________________________ How long? _____________________________________________
Individual/group? __________________________________________________________________________________________
Additional Comments: ______________________________________________________________________________________
Has your child received Therapy anywhere else? □ Yes □ No
If Yes, what services? □ Physical Therapy □ Occupational Therapy □ Speech Therapy
Where? ________________________________________________________________________________________________
By whom? ______________________________________________________________________________________________
Additional Comments: ____________________________________________________________________________________

Are there any religious or cultural issues that we should be aware of regarding your child’s evaluation? _____________________
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PATIENT GOALS FOR THERAPY

What goals are you hoping to have your child accomplish by participating in Therapy? ____________________________________
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ADDITIONAL RELEVANT INFORMATION

THERAPIST USE ONLY:__________________________________________________________________________________________
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GUARDIAN SIGNATURE

To the best of my knowledge I have fully informed you of the history of my child’s problem and current status.

Patient Guardian’s Signature: _______________________________________________________________ Date: _______________________

Relationship to Patient:________________________________________________________________________________________

THERAPIST SIGNATURE
The above information represents all significant subjective findings.
Please refer to the enclosed Objective Findings and Plan of Care for my assessment, treatment goals, and treatment plan.

Therapist’s Signature: __________________________________________License # _________________ Date: ________________

Printed Therapist’s Name: ______________________________________________________________________________________