Medical History Medical History Today's Date(Required) Month Day Year Client InformationClient Name(Required) First Client Name(Required) Last Date of Birth(Required) Month Day Year Medical Background InformationPlease fill out this form as completely as possible. The more information we have, the better we can serve you. If any of the questions DO NOT APPLY TO YOU, please write the word NONE in its space.Client's previous occupational/physical /speech therapy interventions(Required) Client's diagnosis(Required) Medications currently taken and reason for medication(Required)MedicationReason Add RemoveList any allergies(Required) Add RemoveList any special diet(Required) Add RemoveList special precautions needed(Required) Add RemoveList adaptive equipment needed(Required) Add RemoveList any concerns for client(Required) Add RemoveList any goals for client(Required) Add RemoveClient's Mother's Health During Pregnancy(not applicable for adult patients)Did mother have any infections, illnesses or unsual stress during pregnancy? Yes No If Yes, please describe: Did mother's water break more than 24 hours before delivery? Yes No Did mother develop toxemia or high blood pressure? Yes No If so, when? Mother's age at deliveryNumber of previous miscarriagesIf client was born premature, how many weeks?Client's birth weight lbs oz Client's weight at hospital discharge lbs oz Apgar scores at: 1 minute 5 minutes Client's Birth and Postnatal Health(Not applicable for adult patients) Have face presentation? Yes No Have transverse presentation (sideways)? Yes No Have cord wrapped around neck? Yes No Require forceps? Yes No Have insufficient oxygen? Yes No Have respiratory problems? Yes No Small for gestational age? Yes No Have heart defect? Yes No Require exchange transfusion? Yes No Have congenital abnormalities? Yes No Have seizures? Yes No Have infection at birth? Yes No Have feeding problems as a newborn? Yes No Have surgery as a newborn? Yes No Require intensive care? Yes No If yes, for how long? Need respirator? Yes No If yes, for how long? Have jaundice? Yes No If yes, how long under the lights? Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) Last Phone(Required)Email(Required)
