Packet for patients five years of age and older - Atlantic Health System

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PRESENT MEDICAL STATUS Height _________ Weight ___________ Any present illness for which your child is being treated? Y / N _______________________ Does your child take a daily multivitamin? Y / N Flouride? Y / N Medications or supplements child is taking on ongoing basis Y / N. Please note medication and dose___________________________________________________________________________ Are immunizations up to date? Yes / No If No, please explain __________________________________________________ VISION: Do you have any concerns about your child’s ability to see? Yes / No Do you have any concerns about weak eye muscles (lazy eye?) Yes / No Does your child make and maintain eye contact regularly with you? Y / N with others Y / N Has your child been seen by an Eye Doctor? Yes / No Reason and Results: ________________ _________________________________________________________________________________ HEARING: Has your child had history of more than three ear infections within a six month period? Y / N If so when? ________________________________________________________________ Has your child’s hearing been tested by an audiologist since the newborn period? Y/N If so when/where/results ______________________________________________________ Does your child have myringotomy tubes in place? Y / N ____________________________ Has your child ever seen an ENT doctor? Y / N__________________________________ Do you sometimes feel your child does not hear well? Y / N___________________________ Does your child answer to his name when he/she is called most of the time? Y / N Has your child had CAP testing (Central Auditory Processing) Y / N ______________________ APPETITE Use a spoon independently Yes / No Use a fork independently? Yes / No Drink from a straw? Yes / No Eat from all food groups? Yes / NO Do you find your child to be excessively picky regarding food choices? Yes / No Does your child put nonfood objects in their mouth? Yes / No Are you worried about your child’s weight? Yes / No 7
SLEEP What time is child’s bedtime?______________________________________________________ What time do they tend to wake up?________________________________________________ Where do they sleep? (In own bed, co-bed with parent)? ________________________________ Does your child have a hard time settling down to sleep? Yes/ No_________________________ Do they wake frequently during night? Yes / No ______________________________________ Do they snore regularly? Yes / No __________________________________________________ On average, how many hours of sleep do they get a night? ______________________________ Night terrors? Yes / No_____________________________________________________________ Does your child brush teeth before bed? Yes/No__________________________________ Does your child wet the bed? Yes/No ___________________________________________ DEVELOPMENTAL MILESTONES Has your child? Yes / No Age of onset Any Concerns Smiled Sat without support Rolled Crawl Cruise (walk while holding on) Walked without assistance Waving Bye-Bye Clap on request Babble sounds like gaga,dada Use any single word with meaning Said 2-word combinations Said 3-word phrases Began saying sentences Bladder trained, day Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No 8
Page 1 and 2: Dear Parent or Guardian: Welcome to
Page 3 and 4: For children 5 years of age and old
Page 5 and 6: Primary Insurance Insurance Company
Page 7 and 8: THIS FORM MUST BE FULLY COMPLETED C
Page 9: DELIVERY Type of Labor: Spontaneous
Page 13 and 14: SCHOOL HISTORY Current School Name:
Page 15 and 16: HOME BEHAVIOR All children exhibit,
Page 17 and 18: PEER RELATIONSHIPS Is your child in
Page 19 and 20: ADDITIONAL REMARKS Please write any

Packet for patients five years of age and older - Atlantic Health System

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