Adolescent history form - Bronson Total Health Care
Adolescent history form - Bronson Total Health Care
Adolescent history form - Bronson Total Health Care
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*9004142*<br />
Staff Use Only<br />
o Medications need<br />
to be added<br />
Name:_____________________Date of Birth:_________<br />
Physician:____________________ Gender:___________<br />
Affix Patient Label<br />
Tell us About Your Child<br />
Parent or Guardian’s Name:__________________________________________________________________________<br />
Doctor’s Name:______________________________________________________<br />
Phone:___________________<br />
Who referred this child to <strong>Bronson</strong> Rehabilitation Services:________________________________________________<br />
What is the language you use most often at home? o English o Other (specify)_______________________________<br />
Who does your child live with?_______________________________________________________________________<br />
Does your child have access to exercise equipment: o No o Yes: What type?________________________________<br />
Does your child take part in any kind of sports teams (including wheelchair sports)?_____________________________<br />
What hand does your child use most? o Right o Left o Both<br />
What equipment do you use at home to help with exercise or daily activities?___________________________________<br />
_________________________________________________________________________________________________<br />
At the present time would you say your child’s health is: o Excellent o Very good o Good o Fair o Poor<br />
Why Are You Here?<br />
Please mark the area(s) where you are having the symptoms that brought you here.<br />
9004142 (4/13) WH20-BB-ST-No Holes<br />
Intranet<br />
<strong>Adolescent</strong> Check-in Form<br />
Adult and Peds Use<br />
Page 1 of 4
Name:_____________________Date of Birth:_________<br />
Physician:____________________ Gender:___________<br />
Affix Patient Label<br />
Please tell us the reason the doctor sent your child to therapy:_______________________________________________<br />
If this is because of an injury please answer the next few questions. If not please skip to the *<br />
How did This episode begin?<br />
o Auto accident - Date of injury____________<br />
o On the job - Date of injury____________<br />
o Unknown:________________________________________________________________________________<br />
o Other:___________________________________________________________________________________<br />
Did your child’s symptoms begin the same day as the event? o No o Yes<br />
When did the episode start?__________________________________________________________________________<br />
Are the symptoms present 24 hours a day? o No o Yes<br />
*What are your child’s symptoms?_____________________________________________________________________<br />
Have the symptoms changed in the last two weeks? How?__________________________________________________<br />
_________________________________________________________________________________________________<br />
What makes your child feel or per<strong>form</strong> worse?___________________________________________________________<br />
What makes your child feel or per<strong>form</strong> better?___________________________________________________________<br />
Are your child’s symptoms: o Improving o Unchanged o Worse<br />
Do you feel your child has lost strength? o No o Yes Where?____________________________________________<br />
Since your child’s symptoms began, have they experienced any of the following?<br />
o Change in appetite o Dizziness o Nausea<br />
o Change in bowel or bladder patterns o Falls o Ringing in the ears<br />
o Changes to their mood o Fever o Unexplained weight loss or gain<br />
o Changes in vision o Headache o Not applicable<br />
Is your child sleeping through the night? o No o Yes Average hours a night?__________<br />
o Pain wakes my child when they move or turn o Pain wakes my child from a deep sleep<br />
Is there anything your child’s symptoms prevent them from doing?___________________________________________<br />
Medical History<br />
Besides the doctor who sent you, has your child seen any other health providers for This Injury? o No o Yes<br />
1. ________________________________________ Date started:_____________<br />
2. ________________________________________ Date started:_____________<br />
9004142 (4/13) <strong>Adolescent</strong> Check-in Form<br />
Page 2 of 4<br />
Adult and Peds Use
Affix Patient Label<br />
Name:_____________________Date of Birth:_________<br />
Physician:____________________ Gender:___________<br />
What tests have been done? (X-rays, MRI, CT scan, Bone scan, etc.)<br />
_________________________________________________________________________________________________<br />
What were the results?_______________________________________________________________________________<br />
_________________________________________________________________________________________________<br />
Has your child had conditions or symptoms like this in the past? o No o Yes<br />
Did they get treatments for that condition? o No o Yes<br />
Please describe treatments your child has had for a condition like this in the past:<br />
_________________________________________________________________________________________________<br />
_________________________________________________________________________________________________<br />
Medications:<br />
Is your child taking blood thinners? o No o Yes How long?______________________________________________<br />
Has your child taken steroids for this condition? o No o Yes: o Oral o Injection<br />
For any other condition?_______________________________________________________________________<br />
Please list all other medications your child is taking:_______________________________________________________<br />
_________________________________________________________________________________________________<br />
Please check all of the following conditions your child has had:<br />
o Allergies:_________________________________________________________________________________<br />
o Birth defects<br />
o Kidney or bladder infection<br />
o Chronic anemia<br />
o Lung disease or asthma<br />
o Diabetes:__________________________ o Seizures<br />
o Eating disorders<br />
o Previous Head Injury<br />
o Other<br />
o Depression<br />
Does your child have any other conditions that may affect their healing and rehabilitation? (for example<br />
decreased immune system, alcoholism, drug addiction, etc.) o No o Yes<br />
_________________________________________________________________________________________________<br />
_________________________________________________________________________________________________<br />
9004142 (4/13) <strong>Adolescent</strong> Check-in Form<br />
Page 3 of 4<br />
Adult and Peds Use
Name:_____________________Date of Birth:_________<br />
Physician:____________________ Gender:___________<br />
Affix Patient Label<br />
Past Medical <strong>Care</strong><br />
Please list any surgeries or hospitalizations:<br />
____________________________________________________________________________________Year:_________<br />
____________________________________________________________________________________Year:_________<br />
____________________________________________________________________________________Year:_________<br />
____________________________________________________________________________________Year:_________<br />
Please list any fractions or dislocations:<br />
____________________________________________________________________________________Year:_________<br />
____________________________________________________________________________________Year:_________<br />
____________________________________________________________________________________Year:_________<br />
Lifestyle<br />
Does your child have any hobbies? o No o Yes<br />
Please describe:_____________________________________________________________________________________<br />
Please check all that your child use:<br />
o Tobacco (number of cigarettes a day)_____________________________________________________<br />
o Caffeine (number of cups of tea, coffee, soda etc)___________________________________________<br />
o Alcohol (number of drinks a day)________________________________________________________<br />
Is your child (are you) currently in a relationship where they are physically or sexually abused? o No o Yes<br />
Does your child (do you), have a safe place to return to? o No o Yes<br />
Parent or Guardian Signature:______________________________________________________ Date: _____________<br />
Option:<br />
The following individuals have my consent to pick up my schedule or to accept phone calls regarding<br />
my schedule:________________________________________________________________________________<br />
Parent or Guardian Signature:______________________________________________________ Date: _____________<br />
Staff only beyond this line<br />
Copy to: o OT Reviewed by: o OT Initials _______Date:_______Time:_______<br />
o PT o PT Initials _______Date:_______Time:_______<br />
o SLP<br />
o SLP Initials _______Date:_______Time:_______<br />
9004142 (4/13)<br />
<strong>Adolescent</strong> Check-in Form<br />
Adult and Peds Use<br />
Page 4 of 4
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