Thumb sucking Frequent indigestion Nail biting Frequent constipation Epilepsy Frequent diarrhea Heart trouble Vomiting Overtired Frequent Fevers Lack of Appetite Sinus trouble Overweight Nose bleeding Underweight Rashes Frequent headache Frequent ear infections Nightmares Night terrors Asthma Communicable diseases (explain): Allergies (explain): Illness Yes No Age Hospitalization/Where Measles Yes No Age Hospitalization/Where Chicken Pox Yes No Age Hospitalization/Where Mumps Yes No Age Hospitalization/Where Strep Throat Yes No Age Hospitalization/Where Tonsillitis Yes No Age Hospitalization/Where Seizures Yes No Age Hospitalization/Where Meningitis Yes No Age Hospitalization/Where Whooping cough (pertussis) Yes No Age Hospitalization/Where Question Yes No Test Date Test Result Where Does your child have a hearing problem? Yes No Test Date Pass/Fail Where If yes, describe: Adaptive equipment (specify): Does your child have vision problems? Yes No Test Date Pass/Fail Where If yes, describe: Adaptive equipment (specify): Has your child been diagnosed with a Yes No Test Date Pass/Fail Where developmental concern? If yes, describe: Adaptive equipment (specify): List therapy services child has received. Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Social History Please describe your child. Does your child attend a child care program or in-home care? Yes No Where: Notes: Does your child have opportunities to play with other children? Yes No Where:
Thumb sucking Nail biting Epilepsy Heart trouble Overtired Lack of Appetite Overweight Underweight Frequent headache Nightmares Asthma Allergies (explain): Frequent indigestion Frequent constipation Frequent diarrhea Vomiting Frequent Fevers Sinus trouble Nose bleeding Rashes Frequent ear infections Night terrors Communicable diseases (explain): Illness Yes No Age Hospitalization/Where Measles Yes No Age Hospitalization/Where Chicken Pox Yes No Age Hospitalization/Where Mumps Yes No Age Hospitalization/Where Strep Throat Yes No Age Hospitalization/Where Tonsillitis Yes No Age Hospitalization/Where Seizures Yes No Age Hospitalization/Where Meningitis Yes No Age Hospitalization/Where Whooping cough (pertussis) Yes No Age Hospitalization/Where Question Yes No Test Date Test Result Where Does your child have a hearing problem? Yes No Test Date Pass/Fail Where If yes, describe: Adaptive equipment (specify): Does your child have vision problems? Yes No Test Date Pass/Fail Where If yes, describe: Adaptive equipment (specify): Has your child been diagnosed with a developmental concern? Yes No Test Date Pass/Fail Where If yes, describe: Adaptive equipment (specify): List therapy services child has received. Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Type of therapy Therapist Agency/Clinic Phone number Social History Please describe your child. Does your child attend a child care program or in-home care? Yes No Where: Notes: Does your child have opportunities to play with other children? Yes No Where:
pfa-sample-parent-interview.docx