Magnolia Regional Health Center Pediatric Evaluation Form

Personal/Identifying Information
Child’s name: ____________________________________ Date of Birth: ______________

Address: _________________________________________ City, State, Zip:______________________

Phone: _______________________

Mother’s name: ____________________________________ Occupation: ___________________

Personal Phone: __________________________ Work Phone: ___________________

Primary caregiver: Yes No Consent to share health information: Yes No

Father’s name: _____________________________________ Occupation: ____________________

Personal Phone: ___________________________ Work Phone: ______________________

Primary Caregiver: Yes No Consent to share health information: Yes No

 If not mother or father, please fill out following:

Primary Caregiver Name: ______________________________ Relationship: _____________

Occupation: ______________________ Personal Phone: ________________________

Work Phone: _______________________ Consent to share health information: Yes No

Does the child have any brothers and sisters? If yes, list below:

Name: ________________________ Relationship: ______________________ Age:______________

Name: ________________________ Relationship: ______________________ Age:_______________

Name: ________________________ Relationship: ______________________ Age: ______________

Name: ________________________ Relationship: ______________________ Age: ______________

Who lives in the home with the child on a daily basis? Please list names and relationship to child below:
 Prenatal and Birth History
Mother’s general health during pregnancy (illnesses, accidents, medications, etc.):

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Name of hospital where child was born:____________________________________

City, State:____________________________________

Length of Pregnancy:_________________________ Birth Weight:_______________________

Was child hospitalized after birth: Yes No If so, how long was child in NICU (in weeks):__________

Was prenatal care received: Yes No Type of Delivery: C Section Vaginal

Did the mother require medical intervention to achieve pregnancy? Yes No

Were there any unusual conditions at or immediately following birth?

____________________________________________________________________________________

Describe any medical attention mother or child required.

_________________________________________________________________________________
_________________________________________________________________________________

Medical History
Does your child have a medical diagnosis (i.e. Autism, Intellectually disabled, ADHD, etc.)? If so, please
list diagnosis and age diagnosed

_____________________________________________________________________________________
_____________________________________________________________________________________

Check any illnesses that child has had and approximate ages:

Allergies Asthma
Chicken Pox Convulsions
Ear Infections Encephalitis
Headaches High Fever
Influenza Measles
Meningitis Mumps
Pneumonia Seizures
Sinusitis Tonsilitis
Other: ____________________________________________________________________
 Has your child ever been examined by any of the following providers:

Provider Dates of Name of provider Currently Under

Exam/Eval Providers Care
Neurologist Yes No
Occupational Yes No
Therapist
Physical Therapist Yes No
Speech Yes no
Pathologist
Psychologist Yes No
Orthopedic Yes No
Physician
Cardiologist Yes No
Developmental Yes No
Pediatrician
Social Worker Yes No
Behavioral Yes No
Specialist
ENT Yes No

Has the child has any surgeries? If so, what type and when? (i.e. ear tube placement, tonsillectomy,
heart surgeries, etc.):

_________________________________________________________________________________
_________________________________________________________________________________

Is your child currently on any medications? Yes No

Please list names and schedule of medications: ________________________________________
_________________________________________________________________________________

Allergy Yes/No To What Reaction Treatment

Skin

Food

Other: ___________________________________________________________________________
 Developmental History
In your opinion, how does your child’s development compare to that of other children?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

How would you describe your child’s personality?

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_____________________________________________________________________________________

What does your child enjoy doing?

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Check what your child is able to do with approximate age child performed these activities:

Lift head while on belly Roll (back to belly, belly to back)

Sat unsupported Crawled
Stood Cruised
Walked Fed self
Dressed/undressed Self Held objects
Drank from cup Ate with spoon/fork
Used Toilet Bathed himself/herself

SPEECH & LANGUAGE HISTORY

During the first year, other than crying, how would you describe your child:
A silent baby ___________________________
A very quiet baby _______________________
An average noisy baby ___________________
Very noisy baby ________________________
Please describe his/her vocalizations/sounds:
_________________________________________________________.
At what age did he/she say her first word?
_______________________________________________________________________________
Did he/she get one or two words and then go a long time before getting any new words? Yes No

At what age did he/she use two-word combinations like “want cookie?” _____________________

At what age did he/she use complete short sentences like “I go upstairs?” _____________________

Were these easy to understand? Yes No

What efforts does (or did) your child make to communicate his/her wants when not understood?
________________________________________
Did speech learning ever seem to stop for a period?  Yes  No
If so, describe:
_________________________________________________________________________________
_______________ _
How easily can your child follow instructions?
_______________________________________________
Do you have to frequently repeat instructions?  Yes  No
Does he/she seem to have any difficulty hearing?  Yes  No
Does he/she have any visual problems?  Yes  No
What have you done to help your child’s speech and language?
_________________________________________________________________________________
_________________________________________________________________________________

Sensory Information
Does your child appear to be bothered by bright lights? If so, list behaviors below:
_____________________________________________________________________________________
_____________________________________________________________________________________

Does your child have a bad reaction to:

Loud noises Yes No
Dirt, paint, etc. on hands Yes No
Certain food textures Yes No
Having teeth brushed Yes No
Having hair brushed Yes No
Tags in clothing Yes No
Wearing socks or tight clothing Yes No
Car sickness Yes No
Being touched Yes No

Is your child what some might call hyperactive? If so, please describe some of the behaviors that lead
people to say this (i.e. can’t sit still, fidgets, always on the go, etc.).

Does your child seem overly lazy (never wants to do any activities)?

Does your child have a normal response to pain?

 General Developmental/Educational History
Present School: __________________________________________________

City, State:__________________________________________ Grade:_________

Performance in school:

Below Average Average Above Average

List the best/favorite subjects:

_________________________________________________________________________________
_________________________________
List the most difficult/least favorite subjects:
_________________________________________________________________________________
_________________________________
Has your child repeated a grade?  Yes  No
If so, which grade(s)? ____________________
Does your child have an
IFSP  Yes  No
IEP  Yes  No
504 plan  Yes  No

Please list any other services your child receives at school and names of provider (i.e. occupational,
speech, and/or physical therapy, etc.)

Service: _____________________________ Provider Name:__________________

Service: _____________________________ Provider Name:__________________

Service: _____________________________ Provider Name:__________________

Service: _____________________________ Provider Name:__________________

In your opinion, how does your child’s development compare to that of other children?

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

How would you describe your child’s personality?

_________________________________________________________________________________
Why are you bringing your child in for an evaluation? What are the problems you have been
noticing?

What are some goals you have for your child while he/she is receiving therapy?

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