Case History Form

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CASE HISTORY FORM
IDENTIFYING AND FAMILY INFORMATION:
Child’s Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Sex:

MaleFemale
Child lives with (check one)
Please list the name, age, sex, grade of other children in the family:

Rows	Yes	No	Enter Text
Is there a language other than English spoken in the home?
If yes, which one?
Does your child speak the other language spoken in the home?
Does your child understand the language spoken in the home?
Who speaks the other language spoken in the home?
Which language does your child prefer to speak at home?

PATIENT HISTORY
Describe in your own words the type of difficulty your child is having (i.e., what are your specific concerns):
When was the problem first noticed?
Does your child have any medical conditions?
Is your child currently on any medications?

YesNo
Please list any medications your child takes regularly:
BIRTH HISTORY
Was there anything unusual about the pregnancy or birth?

YesNo
If yes, please describe:
How old was the mother when the child was born?
Was the mother sick during the pregnancy?

YesNo
If yes, please describe.
How many months was the pregnancy?
Did the child go home with his/her mother from the hospital?

YesNo
If child stayed at the hospital, please describe why and how long.
MEDICAL HISTORY
Has your child had any of the following?

AdenoidectomyAllergiesBreathing difficultiesChicken poxColdsEar infectionsMumpsScarlet feverEncephalitisFluHead injuryHigh feversMeaslesMeningitisVision problemsSeizuresSinusitisSleeping difficultiesThumb/finger sucking habitTonsillectomyTonsillitis How often?Ear tubesCovid
Other serious injury/surgery:
Is your child currently (or recently) under a physician’s care?

YesNo
Please list any medications your child takes regularly:
DEVELOPMENTAL HISTORY

Please tell the approximate age your child achieved the following developmental milestones:

Does your child...

Choke on food or liquids?Currently put toys/objects in his/her mouth?Brush his/her teeth and/or allow brushingRepeat sounds, words, or phrases over and over?Understand what you are saying?Retrieve/point to common objects upon request (ball, cup, shoe)?Follow simple directions (“Shut the door” or “Get your shoes”)?Respond correctly to yes/no questions?Respond correctly to who/what/where/when/why questions?
Your child currently communicates using..

Body languageSounds (vowels, grunting).Words (shoe, doggy, up).2 to 4 word sentencesSentences longer than four words.Other
Behavioral Characteristics:

CooperativeAttentiveWilling to try new activitiesPlays alone for reasonable length of timeSeparation difficultiesEasily frustrated/impulsiveStubbornRestlessPoor eye contactEasily distracted/short attentionDestructive/aggressiveWithdrawnInappropriate behaviorSelf-abusive behavior
Should be Empty:

CASE HISTORY FORM