Fawzia Sultan Healthcare Network

General Information

First Name

Last Name

Date of birth

Address

Gender

Male

Female

Mother’s Name

Mother’s Occupation

Father’s Name

Father’s Occupation

Phone Number

Mobile Number

Please note that laboratory tests and some preventive health care packages may not be covered by your insurance. If you are unsure if your medical treatment is covered by your insurance, please ask a member of staff for clarification.

Pediatric Medical Questionnaire

Spoken language at home

Comfort in using English

Is the child living with both parents

Yes

Main caregiver

Diagnosis

Child’s Pediatrician

Past Medical History

Does your child now or has ever had any of the following?

Diabetes

Stomach or Peptic Ulcer?

Skin Diseases

High Blood Pressure

Gastric Diseases

Asthma

High Cholesterol

Osteoporosis

Hyperlipidemia

Thyroid Diseases

Osteoarthritis

Bowel Disease

Cancer

Rheumatoid Arthritis

Anxiety

Psoriasis

Pulmonary Embolism

Depression

Kidney Disease

HIV/AIDS

Insomnia

Heart Problems

Pacemaker

Anemia

Tuberculosis

Stroke

Eye Disease

Epilepsy

Hepatitis

Any other previous medical conditions?

Yes, please specify

Previous Surgeries

Previous Procedures

Endoscopy

Colonoscopy

Echocardiogram

Current Medication

Drug allergies

Yes, please specify

Any other allergies? Food or any not known allergies

Please list any medications that you are taking. Include non-prescription medications & vitamins or supplements:

Patient's birth History

Number of

Any complications in pregnancy

Yes, please specify

Any medication during pregnancy

Yes, what it was?

Pregnancy duration

Full term

Preterm

How many weeks

NICU (Newborn intensive care unit) stay

Yes, How many days?

Delivery

Normal

C-Section

Birth weight

Complication after birth

Yes

Medication in the first months

Yes

Any sickness in the first two years
(example jaundice, ear infection...)

Yes

Developmental History

If your child has developmental problem, at what age did they occur?

0-1 months

2-6 months

6-15 months

16-24 months

After24 months

Please indicate the approximate age in months for the following milestones (example: walking 14months)

Sitting up

Never

Dryness at night

Never

Crawl

Never

First words (Mommy, car)

Never

Pulled to stand

Never

Spoken clearly

Never

Walked alone

Never

Lost language

Never

Potty trained

Never

Lost eye contact

Never

Family Mental-Physical History

Any family history of

ADHD

Psychosis

Alcohol/substances

Bipolar

Anxiety

Depression

Has your child received Psychology/therapy before

Yes

Past history of abuse

Yes (if yes what kind of abuse)

Physical

Neglect

Sexual

Psychological

Current risk of abuse

Precocious sexual play/talk

Possible sexual play/talk

Possible physical abuse

Parental concerns/fear of abuse

Previous or current mental health interventions

Yes

Self-harm or harm to others/animal

Yes

Speech-Language History

Family history of speech or language delay

Yes

Has the child received speech-language therapy before

Yes

Family history of hearing loss

Yes

Family history of learning difficulties

Yes

Has the child had feeding or swallowing difficulties?

Yes

Has the child had hearing test before?

Yes

Provide the approximate age at which the child began to do for the following

Ask simple questions (e.g. what’s this? Where is daddy?)

Never

Say single words (e.g. no, mom, dog)

Never

Combine two words (e.g. eat cookie, me go, mommy)

Never

Engage in a conversation

Never

Name things (e.g. eye, cat, car)

Never

Educational History

Does the child currently attend a preschool/school?

Yes

Academic performance

Excellent

Good

Fair

Poor

Behavior at School

Social

Cooperative

Uncooperative

Isolated

Shy

Aggressive

Others

Does the child receive intervention services at school?

Yes

Does the child have Individualized educational plan (IEP) at school?

Yes

Additional information

Pain Injury History

Do you suffer from any of the following

Lower Back Pain

Neck Pain

Knee Pain

Shoulder Pain

Foot Pain

Have you already received treatment for this problem?

Yes

If you feel pain, what score would you give the pain in the last 24 hours

No Pain

Worst Pain in My Life

Is the pain constant or are there times when you feel pain free?

Constant

Period with no pain

How long have you had this problem?

Did your symptoms start gradually or was there an event / accident that caused the problem?

Gradually

Started at a specific time

I declare i have filled out the above information honestly and to the best of your knowledge.

I Accept Service Contract

Pediatric Registration

General Information

Pediatric Medical Questionnaire

Past Medical History

Current Medication

Patient's birth History

Developmental History

Family Mental-Physical History

Speech-Language History

Educational History

Pain Injury History