Medical History

Medical History

Today's Date(Required)

Client Information

Client Name(Required)
Client Name(Required)
Date of Birth(Required)

Medical Background Information

Please 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.
Medications currently taken and reason for medication(Required)
List any allergies(Required)
List any special diet(Required)
List special precautions needed(Required)
List adaptive equipment needed(Required)
List any concerns for client(Required)
List any goals for client(Required)

Client's Mother's Health During Pregnancy

(not applicable for adult patients)
Did mother have any infections, illnesses or unsual stress during pregnancy?
Did mother's water break more than 24 hours before delivery?
Did mother develop toxemia or high blood pressure?
Client's birth weight
Client's weight at hospital discharge
Apgar scores at:

Client's Birth and Postnatal Health

(Not applicable for adult patients)
Have face presentation?
Have transverse presentation (sideways)?
Have cord wrapped around neck?
Require forceps?
Have insufficient oxygen?
Have respiratory problems?
Small for gestational age?
Have heart defect?
Require exchange transfusion?
Have congenital abnormalities?
Have seizures?
Have infection at birth?
Have feeding problems as a newborn?
Have surgery as a newborn?
Require intensive care?
Need respirator?
Have jaundice?

Responsible Party Information (Client or Parent/Guardian)