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    TOTs Forms Case History PEDIATRIC Updated

    Uploaded by

    Mohamed Elgendy
    This document contains a pediatric case history form seeking information about a child's birth history, medical history, dental history, feeding history, oral-motor skills, and any previous or current therapy. The form includes questions about pregnancy, delivery, medical diagnoses, allergies, feeding difficulties, speech intelligibility, and sound production. Responses will help assess the child's development and identify any areas that may need evaluation or treatment.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    TOTs Forms Case History PEDIATRIC Updated

    Uploaded by

    Mohamed Elgendy
    11 views10 pages
    This document contains a pediatric case history form seeking information about a child's birth history, medical history, dental history, feeding history, oral-motor skills, and any previous or current therapy. The form includes questions about pregnancy, delivery, medical diagnoses, allergies, feeding difficulties, speech intelligibility, and sound production. Responses will help assess the child's development and identify any areas that may need evaluation or treatment.

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    TOTs-Forms-Case-History-PEDIATRIC-updated

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    This document contains a pediatric case history form seeking information about a child's birth history, medical history, dental history, feeding history, oral-motor skills, and any previous or current therapy. The form includes questions about pregnancy, delivery, medical diagnoses, allergies, feeding difficulties, speech intelligibility, and sound production. Responses will help assess the child's development and identify any areas that may need evaluation or treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    11 views10 pages

    TOTs Forms Case History PEDIATRIC Updated

    Uploaded by

    Mohamed Elgendy
    This document contains a pediatric case history form seeking information about a child's birth history, medical history, dental history, feeding history, oral-motor skills, and any previous or current therapy. The form includes questions about pregnancy, delivery, medical diagnoses, allergies, feeding difficulties, speech intelligibility, and sound production. Responses will help assess the child's development and identify any areas that may need evaluation or treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 10

    Appendix A

    MERKEL-WALSH & OVERLAND


    Pediatric Case History Form

    First Name

    Last Name

    Date Birth

    Address

    Home Cell

    Referring Physician

    Date of Report

    Birth History
    (please provide details where applicable)

    Question Yes No

    Were there any complications during pregnancy

    Did you carry your baby full term?

    Were there problems during delivery?

    Did your baby require any special care after delivery?


    Birth weight

    Percentile of weight

    Length/height

    Percentile of
    length/height

    Apgar Score

    Medical History

    Question Yes No

    Does your child have a medical or educational diagnosis?

    Has your child ever been on medication?

    Is your child currently on medication?

    Does your child have any of the following? (check all that apply)

    Frequent Colds Seasonal allergies

    Chronic Congestion Food allergies

    Asthma Hearing Issues

    Cardiac Issues Constipation

    Tracheomalacia Frequent spit-up

    Reflux/GERD Snoring

    Failure to thrive Bed-wetting

    Diagnosis of sleep apnea Recurrent middle-ear infections

    Laryngomalacia Diarrhea

    Frequent vomiting (after six months of age) Restless sleep


    Dental History

    Question Yes No

    Has your child been seen by a dentist?

    Does the dentist have any concerns about structure? (If yes, check all
    that apply below)

    High Palate Teeth Grinding/Bruxism

    Cavities Plaque

    Lip-Tie Spaces between teeth

    Crowding Tongue-Tie

    Thrush Frequent spit-up

    Feeding History

    Was your baby breast- or bottle-fed?

    Breastfed Bottle-fed

    How did you originally plan to feed your baby?


    Question Yes No

    Are there any concerns about nutritional status?

    Do you have any concerns about feeding safety?

    Has your child had a swallow study? (If so please attach the results)

    Did you seek assistance with breastfeeding? PCP Lactation SLP


    Consultant
    (IBCLC)

    Question Yes No

    Was a lip-tie or tongue-tie identified?

    Were you encouraged to see/discouraged from seeing a specialist?

    Did you child have any difficulty breastfeeding/bottle-feeding (if


    yes, please check all that apply below)

    Difficulty latching Reflux

    Coughing Gagging

    Crying Dribbling

    Other:

    At what age did you introduce spoon-feeding?


    Question Yes No

    Did your child have any difficulty with smooth pureed food? (if yes,
    please check all the apply below)

    Coughing Spitting out food

    Vomiting Choking

    Gagging Food Refusal

    Other:

    Question Yes No

    Did your child have any difficulty with chunky pureed food? (if yes,
    please check all the apply below)

    Coughing Spitting out food

    Vomiting Choking

    Gagging Food Refusal

    Other:

    At what age did you introduce solid foods?


    Question Yes No

    Did your child have any difficulty with dissolvable solids (ex., Cheerios,
    Puffs) (if yes, please check all the apply below)

    Coughing Spitting out food

    Vomiting Choking

    Gagging Food Refusal

    Other:

    Question Yes No

    Did your child have any difficulty with soft vegetables/fruits? (if yes,
    please check all the apply below)

    Coughing Spitting out food

    Vomiting Choking

    Gagging Food Refusal

    Other:
    At what age did your child stop breast- or bottle-feeding?

    Question Yes No

    Did your child have difficult transitioning to a straw?

    Did your child have difficulty transitioning to a cup?

    Is your child on a special or restricted diet (e.g., glute-free, dairy-


    free) (If yes, please describe below)

    Does your child have a self-limited diet? (e.g., gluten-free, dairy- Yes No
    free) (if yes, please describe below)

    Does your child have food aversions? Please indicate difficulties Yes No
    with taste, texture, temperature, color, size and/or shape

    Are mealtimes longer than normal? Yes No

    Would your child prefer to graze rather sit for a meal? Yes No
    Please chart what your child eats (item and amount) in the following Five-Day Baseline Diet:

    Five-Day Baseline Diet

    Day 1 Day 2 Day 3 Day 4 Day 5

    Breakfast

    Snack

    Lunch

    Snack

    Dinner

    Snack

    Oral-Motor/Oral Habits

    Question Yes No

    Has your child had excessive drooling?

    Does your child suck his/her thumb or digits?

    Did your child use a pacifier? (if yes, enter how long below

    Does your child exhibit open-mouth posture and mouth breathing?


    Oral-Motor/Oral Habits
    Is your child’s speech intelligible to the familiar listener?

    <25% 25-50% 50-75% 75%

    Is your child’s speech intelligible to the unfamiliar listener?

    <25% 25-50% 50-75% 75%

    Does intelligibility change as your child moves from single words to sentences?

    Question Yes No

    Do you have any concerns about sound production? (If yes, what
    sound(s) does your child have difficulty producing (circle sounds that
    apply)

    If yes, what sound(s) does your child have difficulty producing (check sounds that apply)?

    b m p w t d n l k

    g h r sh ch j s z j

    r l s k th Vowels
    blends blends blends blends
    Therapy

    Question Yes No

    Has your child been seen a lactation specialist? If yes, please provide
    name below

    Has your child been seen for feeding therapy (If yes, please provide name
    of treating therapist below

    Has your child been seen for speech therapy? (If yes, please provide
    name of treating therapist below)

    Additional Information (Feel free to use the back of this form.)

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