Case History

Please fill out the following history form. Omit any questions that do not apply to you. All information is CONFIDENTIAL

Date: Child's name:

Birthdate: Age:

Address: City:

Zip code: Home phone:

Email:

Father's name: Mother's name:

Dadwork phone: Dad cell:

Momwork phone: Mom cell:

Altername contact name:

Alternate Contact's number:

Child lives with: Mother Father Both parents Other
What languages are spoken in the home?
What is the primary language your child prefers?

Reason for seeking evaluation:

What do ou hope to know after your visit to our office today? Referred by: Doctor Friend Teacher Other

Developmental History

Mother's general health during pregnancy: Poor Good Excellent
Mother's age at time of child's birth:
Mother on bed rest? Yes No

Why?

Length of pregnancy: weeks
Delivery: Vaginal Cesarean
Was labor induced or drugs used? Yes No
Forceps or suction used? Yes No

Where there any complications during the pregnancy or at birth?

Birth weight: lbs oz
Was the child in NICU? Yes No How long?
Breast fed Bottle fed Both

Where there any difficulties with feeding?

When was your child weaned to a cup?
Can your child drink through a straw? Yes No
Is your child a: good eater picky eater
What types of foods does your child like to eat?
Are there any foods that cause your child to gag, choke, throw up, or have a tantrum?

Has your child or does he now any difficulty with:
Swallowing Chewing Eating Drooling Reflux

Ages of:

Rolled over: months

Sitting up unsupported: months;

Crawled: months;

Pulled to stand: months;

Stood without support: months;

Walked alone: months;

First word: months;

Use of short phrases/sentences months;

Potty trained: months;

Undressed self: months;

Used eating utensils: months;

Used buttons, zippers, snaps: months;

Tied shoes: years;

Skipped: years;

Rode tricycle: years;

Rode bicycle: years;

Used scissors: years;

Used writing untensils: years;

Does your child have a strong reaction/dislike to any of the following? (click all that apply)
Tooth brushing Hair cutting Fingernail clipping Loud noises
Bright lights/sun Socks/shoes Shirt tags Hair washing

Medical History

Name of child's doctor:

Name of clinic and location:

Phone:

Name of child's dentist:

Name of clinic:

Phone:

How is your child's general health?

Does your child breath primarily through: Mouth Nose Both
Does your child snore? Yes No
List approximate ages of any ear infections:
Were ear infections: Constant Frequent Occasional Rare
Was the insertion of PE tubes (ear tubes) ever discussed? Yes No
If so, explain:

Date of insertion:
Number of insertions:
Are tubes currently in place? Yes No
Has your child ever had any surgeries?

Does your child have a medical diagnosis (i.e. autism, cerebal palsy, etc)?

Is there any family history (including extended family: grandparents, uncles, aunts, cousins, etc) of speech, language, hearing, attention or learning issues?

Did they recive any intervention? Yes No

If so, what was the outcome of the intervention?

Is there any concern with your child's hearing? Yes No
When was it last tested? Where? Results?

Has your child ever exhibitied or had any of the following?
Seizures Extended high fever Meningitis Periods of blank staring Strong fears or dislikes Traumatic injury (i.e brain injury / motor vehicle accident)
Difficulty with sleeping

Does your child have allergies or asthma? Yes No
Please list:
Is your child currently on any medications? Yes No

Please list type and frequency:

Educational History

Age entered school: Present grade: School: Teacher's name:
Has your child ever been held back a grade? Yes No
My child's grades in school are:
Above average (A,B) Average (C) Below average (D,F)
My child's favorite subject in school is:
Least favorite:

My child exibits:
Difficulty reading Difficulty spelling Difficulty following directions
Daydreaming during class Overall fustration with learing
Poor handwriting/letter formation Poor memory
Right-left confusion/directionality problems Poor or late letter recognition
Poor organization Poor concentration

Has your child received speech therapy services or an evaluation in the past?
Yes No
If so where? How long?
What was recommended?
Has your child received occupational therapy services or an evaluation in the past?
Yes No
If so where?
How long?
What was recommended?

How would you describe your child's personality?

Does your child get upset easily?
Would you say that he is a worrier or an anxious child?
Is he a child who likes routines? Yes No Sometimes
Does he become upset if his routine is altered?
How does your child get along with other children?
Does he have friends?

What type of discipline works best with your child?

On a scale of 0-7 (where 0 is normal and 7 is very severe), how would you rate your child's issue at this time?
On a scale of 0-7 (where 0 is not aware at all and 7 is very aware), how would you rate your child's awareness level of his / her issue at this time?

Social History

Father's occupation:

Mother's occupation:

Age:

Age:

Highest grade completed:

Highest grade completed:

Child's siblings: _{(Name,age,sex)}

1. 2.

3. 4.

What is your child's favorite activity?

Indiviual providing information:

Mother Father Other

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