Medical History Form – DMA-6 History – Medicaid Application / Renewal

Here is a Medical History template for you to use for keeping accurate record of your child’s medical condition.

I use this form for the medicaid application and renewal with the words in the DMA-6 History – “See attached”. It is also useful for taking to doctor appointments and accessing information quickly. Also google “medical history form” for ideas and charts. There is so much available now on the web. Fill them in with the information below.

Start filling out your child’s medical history as soon as possible and keep it updated on your computer. I name the file “Corey Lange Medical History – Year”. Every year I rename the file with the current year and “Save As”. Pick a time of year that makes sense for you. I do it at the time of medicaid renewal.

Gather information from your baby books, medical records, evaluations, IEPs, school records, etc. The doctors will ask for the milestones for years to come, medicines you have tried and why you went on and off, information on pregnancy, complications and first signs of disability. They will ask so many questions especially in new doctor visits that it is good to have it all down in one place for quick and easy reference. Then give the doctor a copy of it for their records.

This form does not include everything for every diagnosis but it gives you a starting place.

Do not give up. Just break it down in to small pieces. Maybe just start with name, address, birthdate, and the easy stuff. Save and come back to it as time allows.

Make a hard copy and a digital copy – flashdrive preferred for longer lasting data time. CDs/DVDs only have a 10yr lifespan and can get scratched easily. Store in a safe place such as a firesafe or make an extra copy for a family member not in your home. You would not want all your hard work to disappear and this will go with your child for life.

Best wishes to you and your family.

Name – Medical History
Address – Phone
Birthdate: Age: Medicaid #

Complete Diagnosis:

Family Information:

Dad – Name, age, job, health
Mom – Name, age, job, health
Sibling(s) – Name, age, job/schoool, health


Pregnancy – length, any complications or concerns
Delivery – Date, location, doctor, baby height, weight, apgar score, etc.
Complications –

Developmental Delays First Detected:


Education – Grade, classroom, school
Occupational Therapy – hours per week at school and private with name of business/therapist
Speech Therapy – hours per week at school and private with name of business/therapist
Physical Therapy – hours per week at school and private with name of business/therapist.
Past – examples: Hippotherapy, karate and swim lessons

Medical Information: ( In each section below list history – appointment results and actions, doctors, dates, test results, etc.)

Allergies –

Current Medications –

Immunizations – ex. Fully immunized up to Georgia requirements

Hearing –

Dental –

General –

Vision –

Adaptive Equipment –

Hospital History – list stays at hospital: date, doctor, name of hospital and city, state, reason and results

Tests – Testings not listed in above categories

Genetic Testing –
Test 1: Date, Type of test, results and location/doctor, note if you have the report or done in research
Test 2:
Test 3:

Evaluations – (I put this in a table but it won’t show on this site)

Date Doctor(s) Type of Eval. Location, Facility

Nutritional History

Body Stats – (I put this in a table but it won’t show on this site)
Date Weight Kg/ x 2.2 = lbs +/- lb Height +/- BP

History of Medical Condition(s)

This is where you can list initial diagnosis and the progression to current diagnosis.
Seizure logs, Etc.

History of Medicines
(I put this in a table but it won’t show on this site)
Medication Last Dosage Start Date Stop Date Reason On Reason Off

List of Firsts (I put this in a table but it won’t show on this site)


First words, sounds, sit up, roll over, crawl, pull up, walk, 2 word sentence, etc.

Current Functioning:
Also see therapist evaluation and care plans, IEP and psychodevelopmental evaluation for details and test scores.

Self Help –
Bathing –
Hair –
Teeth –
Dressing –
Eating –
Chores –
Toileting –
Routine – on own or uses list, verbal cues and prompts, visual aids, etc.
Medicine – taking medicine

Behavior –

Focus/impulse –

Fine Motor Skills –

Gross Motor Skills –

Social Skills –

Language/Speech –

Cognitive –

Strengths: (sample ideas – gather from IEP, therapy evaluation and psychological eval, teacher and parent input)
1. Great personality. Caring, sharing, hugs and kisses, silly, funny and great laugh and the sweetest smile. Wants to make others happy.
2. Works hard and many hours to progress and is proud of himself when he succeeds. Persistent and determined.
3. Very good medical treatment and early care has shown great improvement.
4. Full parent and family love, support and involvement.
5. Good school support and loving, knowledgeable teachers and staff.
6. Quality direct and supervised skilled care received on intense, consistent basis is showing response towards independent functioning.
7. Visual understanding.
8. Enjoys life and playing. Likes music, animals, friends, running, construction vehicles, trains, sand, bubbles and computers among other things. Creatively makes clouds into objects as we watch the sky.

Needs: See IEP and therapy goals for further needs
(sample ideas – gather from IEP, therapy evaluation and psychological eval, teacher and parent input)

1. Increase eye contact when communicating
2. Have appropriate social greetings and verbalize a response
3. 2 way conversations
4. Indicate the need to go to the bathroom and go to the bathroom on own without routine
5. Increase proprioceptive awareness
6. Increase oral motor strength for eating
7. Improve rotary chewing and strength
8. Learn to swallow medication
9. Learn to lean back and open mouth without gagging for dentist
10. Increase balance
11. Increase fine motor and bilateral coordination skills
12. Increase strength, range and grasp of upper/lower extremities
13. Increase sensory processing to enhance ADLs, fine motor, visual motor/perceptual skills
14. Button clothing independently
15. Independent dressing without prompts
16. Develop independence in hair and teeth brushing
17. Tie shoes and bathrobe independently
18. Maintain visual tracking and scanning and visual motor integration
19. Improve planning, organization, and self-monitoring skills
20. Increase ability to attend, focus and stay on task
21. Improve ability to follow two to three step directions
22. Decrease impulsivity
23. Decrease frustration and stress – learn how to deal with anger
24. Increase ability to be aware of and avoid dangerous situations, ie. Crossing the street, stove, knives, etc.
25. Improve body awareness and left, right distinction
26. Ability to predict events in a story when prompted, help predict life situations
27. Demonstrate comprehension of quantitative and spatial concepts
28. Understanding why, when, where, how questions
29. Improve reading, math, money, time skills for basic living independence
30. Improve transitioning from what he wants, to what needs to be done
31. Doing homework or eating without a fuss or tantrum
32. Decrease nighttime anxiety with darkness and separation

Level of Care:
1. Must be intensive, consistent 7 days a week, 24 hours a day and include multiple medical services
2. Must address Corey’s significant limitations and deficits in self care, understanding and using language, learning, mobility, self direction, and capacity to live independently
3. Must address his medical issues of multifocal seizures and focusing with medicine intake, and eating
4. Must be direct from therapists and overseen and modified as necessary by therapists
5. The level of care goes well beyond what a typical child requires.

Conclusion (not necessary but this is what we write)

Without all the therapies and medical care many doctors say Corey would be more severely disabled with his neurological condition. It was very fortunate that he was able to begin receiving skilled training and care at 18 months. Corey receives therapy and daily living training everyday either by his parents, school therapists and/or private therapists to continue to make progress and maintain current levels.

He is making great progress this year towards independence on daily living and his world around him. He has a wonderful team encouraging and teaching him. His own determination and perseverance helps him achieve many things others thought he was incapable of doing. The “I did it” makes it all worth it.

Without Medicaid we would not be able to pay for Corey’s expensive seizure medications and medical care, which has kept the worst seizures at bay for many years. Please consider giving us Medicaid again so Corey can have a healthy and productive life.

Thank you!

Signed Parents

Sample of Possible Doctor Letter for Medical Necessity

Letter of Medical Necessity:

“Patient” is a ## year old boy/girl with “condition(s)”. He/she is responding well and making progress with the intensive therapies, medication and medical services. “Patient” continues to improve towards independence with determination and persistence. It is imperative “Patient” continues to receive Medicaid for his medication and medical treatment for his “condition(s)” along with his/her therapies for continued improvement in daily living abilities.

Dr. Name _________________________________________ Date ___________

(use footer on every page in case they get separated): CHILD NAME Birth: year PHONE Page 1 Date