Schreiber Pediatric Rehab Center Portable Medical Profile
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- Betty Rosaline Alexander
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1 I. Demographic Information Schreiber Pediatric Rehab Center Portable Medical Profile A. Client DOB II. Family Composition and History A. Please list all people living with the child in your home. Name DOB Relationship Workplace/School B. Is Your Child Adopted Foster Care Date of Adoption Date placed in Foster Care C. If child is living with only one biological parent, name and address of other parent? (If involved with child). D. Are there any cultural preferences or considerations of which we should be aware? E. Please list any history of hearing loss, speech delay, fine or gross motor problems and/or learning difficulty by any members of your family living or deceased. Family Member Problem Treatment/Meds 1
2 III. Pre-School / School Information A. School child attends School District: Grade Teacher: IU 13. Yes or No B. Does your child receive Early Intervention: yes no Birth to Three E.I. Support Coordinator IU#13 Early Intervention Service Coordinator C. Does your child receive any of the following supports in their school program? Life Skills Multi-Handicap Vision Support Resource Room Mobility Training Diag. Kindergarten Hearing Support Learning Support Autistic Support Physical Therapy Occupational Therapy Speech Therapy IV. Agencies, Hospitals, and/or Other Programs involved with the child and/or family and dates of attendance Primary Care Provider (name) Physical Therapy Occupational Therapy Speech/Language Therapy Feeding Clinic Children & Youth Services Church Support Groups Other Support Groups Other Family Support Services 2
3 V. Child s Birth & Medical History A. Pregnancy / Delivery Length of Pregnancy: Duration of Labor: Birth Weight lbs. oz. inches Anesthesia Used: B. Hospital of Birth: Specialized Care or NICU How Long: C. Type of Delivery: Natural Induced Caesarean Section D. Did you receive any pre-natal care Yes or No *Please answer the following questions if you experienced any complications during your pregnancy which you would like to share with the therapist(s). E. Pregnancy:* Illness Medications Asthma Heart Problems Premature Contractions Bleeding Amniocentesis Genetic Counseling Mental Health/Stress Other Difficulties F. Did your child experience any of the following: Premature Birth Need Resuscitation or Difficulty breathing upon delivery Jaundice Sucking/Swallowing Problems Breech Frequent Illness History of Ear Infections Feeding Problems Other: 3
4 G. Medical History 1. Diagnosis(es) 2. Current Medications (name, dosage, frequency) 3. Hospitalizations or Surgeries: Name Dates For What? 4. Immunizations: Are your child s immunizations up to date? yes / no 5. Allergies 6. What Equipment of Devices does the child use to help him access his/her environment (wheelchair, crutches, hearing aid, prosthesis, communication device, etc.) 7. What is the child s functional status? Area Gross Motor Fine Motor Self-Care Communication Personal/Social Swallowing/Feeding Vision Hearing Age Appropriate Slightly Moderately Significantly Comments: 4
5 V. Emergency Information VI. A. Please indicate two persons who we may contact in case of emergency and parent/guardian is not present. Name Relationship Address Phone B. In the event that your child needs to be taken to the hospital, unless otherwise indicated, they will be transported to the closest hospital by emergency medical personnel. Hospital Choice C. Does your child / parents or legal guardian on behalf of child have an advanced directive (eg., Do Not Resuscitate order (DNR), etc.) yes / no If so, is it applicable in this setting? yes / no If yes, it is the responsibility of the family to provide this legal document to the Social Services Department upon enrollment in programming, and to keep the Center informed of updates to the order pursuant to our policy #. Health Insurance Information A. Primary Insurance Company ID# Group # Name of Insured Date of Birth Employer B. Secondary Insurance Company ID# Group # Name of Insured Date of Birth Employer Date Updated Signature of Responsible party Printed Name 5
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