Case History Form
Client and Family
Client's name
First Name
Last Name
Client's Date of Birth
-
Month
-
Day
Year
Date
Age:
Gender
Male
Female
Primary language(s) spoken in the home:
*
Primary reason for bringing your child to see us:
Parent/guardian name 1:
First Name
Last Name
Mother/Father
Mother
Father
Phone Number
-
Area Code
Phone Number
Phone
Home
Mobile
Work
Phone Number
-
Area Code
Phone Number
Phone
Home
Mobile
Work
Parent/guardian name 2:
First Name
Last Name
Mother/Father
Mother
Father
Phone Number
-
Area Code
Phone Number
Phone
Home
Mobile
Work
Phone Number
-
Area Code
Phone Number
Phone
Home
Mobile
Work
Client lives with
Birth parents
One parent
Grandparent(s)
Family member
Adoptive family
Foster family
Parent and step parent
Other
Others living in the home:
Parent/guardian address 1:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/guardian address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sibling names/ages
Client spends most days at
Home
In-Home daycare
Daycare center
Grandparents
Preschool
School
Other
If in school, please provide name of school, present school hours and days of the week in attendance:
Does school work seem inadequate in any areas?
yes
no
If you answered yes to the above questions, what are your concerns?
Describe any family history of developmental delays
Insurance
My child's primary health insurance is with:
Member/Policy Number
Policy Group Number
Name of policy holder
Policy holder's date of birth
-
Month
-
Day
Year
Date
Primary care physician's name
Primary care physician's phone number
-
Area Code
Phone Number
Phone Number for Providers (often on the back of your insurance card)
-
Area Code
Phone Number
Insurance plan effective date
-
Month
-
Day
Year
Date
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Birth and Medical History
Pregnancy:
Full term
Premature
Number weeks gestation
Birth weight
Was mother's condition during pregnancy good to excellent?
yes
no
Were medications taken during pregnancy?
yes
no
Does child have any known allergies?
yes
no
list any allergies:
Pregnancy/birth complications, if any
Were labor and delivery normal?
yes
no
if you answered no to above question, please explain
Was labor induced?
yes
no
Was there evidence of injury or poor health at birth?
yes
no
If you answered yes to the above question, please explain
During the first month of life, was child's health good to excellent?
yes
no
If you answered no to the above question, please explain
Current medical or educational diagnosis:
*
Please comment on any medical history thus far (hospitalizations/surgeries
Passed newborn hearing screening?
yes
no
Current hearing concerns?
yes
no
Has hearing been tested by an audiologist?
yes
no
yes, but not by an audiologist
Date of last hearing test and results:
*
History of ear infections?
yes
no
If applicable, date of PE tube placement
Vision concerns?
yes
no
If you answered yes to above question, please explain
Please list any current medications:
Developmental History
When did child achieve the following milestones?
Roll over (typically occurs between 4-6 months of age)
Earlier than expected
As expected
Later than expected
Sit independently (typically occurs between 6-8 months of age)
Earlier than expected
As expected
Later than expected
Crawl (typically occurs between 7-10 months of age)
Earlier than expected
As expected
Later than expected
First independent steps (typically occurs between 12-15 months of age)
Earlier than expected
As expected
Later than expected
Does your child toe walk?
yes
no
Does your child "W" sit?
yes
no
Is your child usually clumsy?
yes
no
Can child pick up small objects with finger and thumb?
yes
not yet
Did child coo and babble as a baby (prior to 12 months of age)?
yes
not much
no
How does child communicate wants and needs?
looks at objects
points and grunts
reaches
uses pictures
gestures
signs
whines
cries
leads adult
uses words
How many different consonant sounds does child produce?
At what age did child acquire first words?
Does the child talk in vowels only?
yes
no
About how many words/word approximations does child say currently?
How frequently does child say these words?
consistently
randomly and sporadically
Does child have a history of saying a word or phrase one time and never saying it again?
yes
no
Does child put 2 words together?
Not yet
Occasionally
Consistently
Does child imitate what other people say and do?
Not yet
Occasionally
Consistently
Does child say new words on a regular basis?
Yes
Not as expected
Does child talk in (check all that apply):
Single words
Phrases
Complete but grammatically incorrect sentences
Grammatically correct sentences
None of the above
Does child retell stories or experiences that can be understood?
yes
no
Does child follow simple commands? (e.g. "get the ball")
Not yet
Occasionally
Consistently
Has child ever had a speech and language evaluation or therapy?
yes
no
If you answered yes to above question, please provide details (date, by whom, where, results)
Pacifier use or thumb sucking:
During the day occasionally
Only when sleeping
When upset
No longer uses pacifier or thumb sucks
Prefers to at all times
Never had one/never thumb sucked
Did child orally explore/put everything in mouth as a baby
yes
no
Does child still mouth non-edible items?
No
Occasionally
Excessively
Does child drool?
No
Occasionally
Excessively
Only when teething
Does child eat a wide variety of foods?
Yes
Is somewhat picky
No, eats limited variety of foods
Do certain food textures bother the child? If yes, describe
How independent is child at mealtime?
Feeds self with utensils
Feeds self with fingers
Fed by caregiver
How does child drink liquids?
Bottle
Sippy cup
Straw cup
Open cup
Does child present with a tongue thrust?
yes
no
I don't know
Does child present with a tongue or lip tie?
yes
no
I don't know
repaired
Does child tolerate teeth brushing?
Yes
Chews on the brush
Is defensive/does not tolerate
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Developmental History (continued)
Describe child's temperament
Content
Determined
Spirited
Curious
Friendly
Active
Cooperative
Independent
Stubborn
Noisy
Quiet
Demanding
Laid back
Social
Patient
Slow to warm up
Silly
Shy
Cautious
Frustrated
Observant
Difficult to handle
How easily does child transition from one activity to another?
Typically, no difficulty with transitions
Sometimes struggles with transitions
Transitions are often difficult
How does your child respond to being told no
Complies
Ignores
Doesn't seem to understand
How well does child comply with adult requests?
Complies
Ignores
Doesn't seem to understand
How often does child have tantrums/meltdowns?
Rarely
A few times per week
Daily
Can child self-calm?
Yes, meltdowns are usually brief
Self-calming is difficult for my child
Sensory Processing
adapted from Lucy Jane Miller's book, Sensational Kids
Is child bothered by any of the following?
Loud or unexpected noises
Having dirty or sticky hands
Being barefoot in the grass
Having hair or nails cut
Certain food textures
Bright lights
Being upside down
Being in loud or crowded places
Tight-fitting clothes such as hat, jeans or coat
Changes in routine
Do any of these symptoms apply to the child?
Doesn't cry when hurt/high pain tolerance
Is difficult to engage
Seems unaware of what's going on around him/her
Prefers sedentary activities (such as screen time) to active, physical play
Slow or unmotivated to learn to do things for self (such as dress or feed self)
Doesn't respond when name is called
Unaware of being cold, hot or hungry
Seems to be in own world much of the time
Does child exhibit any of these behaviors?
Seeks unusual amounts of movement; likes to jump, climb, and roughhouse more than other kids his/her age
Strong preference for spinning, swinging, flapping hands, banging head
Touches objects or people excessively
Takes bold risks during play; has no fear
Likes music/TV at high volumes
Fixates visually on objects; lines up toys or other objects and visually scans them repeatedly
Prefers foods with strong flavors (e.g. pickles, lemons, hot peppers)
Licks or chews on non-food items
Makes odd noises just to hear them
Is nearly impossible to take the movies, church, or places that don't allow much movement/noise
Social Emotional
Describe how child interacts with parents, siblings, grandparents and other family members:
Does child enjoy the company of other children?
Often
Sometimes
Not usually
How does child respond when you have to separate from him/her?
Does child play with children who are older? younger? same age?
Describe some activities you and your child enjoy doing together:
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Daily routines
Bedtime/sleep
Does your child snore?
yes
no
occasionally
Is child a mouth breather?
yes
no
Where does child usually sleep?
Does child take naps during the day?
yes
no
occasionally
If your child naps, do the naps happen on a schedule or at random times?
Describe nightly bedtime routine if there is one:
Describe sleep habits to include restlessness, consistent hours per night, issues with chronic sleeplessness, unable to sleep in his/her own bed
Playtime
Describe child's favorite play time activities and toys:
Does child show interest in a wide variety of toys?
yes
no
Does child explore new toys eagerly and appropriately?
yes
no
Does child demonstrate purposeful play with toys (such as kicking a ball, stacking blocks, reading books, driving toy cars, feeding a baby doll)?
yes
no
Does child bring toys and books to share with caregivers?
yes
no
Does child attend to toys AND play partners during play?
yes
no
Does child indicate need for assistance during play time?
yes
no
Can child entertain self for brief periods of time?
yes
no
How much screen time does have each day?
What does child like to do when playing outside?
Describe any concerns you have regarding his/her play routines:
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