Pediatric Case History Form
Speech-Language Therapy, Occupational Therapy, and/or Physical Therapy
Demographic Information
Date of Form Completion:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Name
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First Name
Last Name
Client's Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
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Gender
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Diagnosis (if known)
Parent/Guardian Name
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First Name
Last Name
Emergency Contact Name (other than primary caregiver)
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First Name
Last Name
Emergency Contact Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
How Did you Hear About Communication Cottage Therapy, LLC?
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Family Background
Parent #1 Name
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First Name
Last Name
Parent #1 Age
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Parent #1 Occupation
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Parent #1 Education Level
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Parent #2 Name
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First Name
Last Name
Parent #2 Age
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Parent #2 Occupation
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Parent #2 Education Level
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Marital Status
single
married
divorced
separated
widowed
Other
Who does the child live with? (list all family members, relationship(s) to the client, sibling(s) name(s)/age(s))
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Any known delays, diagnoses or related difficulties associated with any other siblings/family members in the child's life?
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Language(s) spoken in the home
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Who speaks the other languages
Primary Language in home
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Is there anything additional that you would like to share about the family/home environment?
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Evaluation
Describe in your own words the nature of your concerns about your child's development and/or the primary referral reasons?
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At what age did you first have concerns?
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Gestational History
Women's Health During Pregnancy:
Were there any infections or illnesses during pregnancy?
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yes
no
Describe:
Was there any stress during the pregnancy?
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yes
no
Describe:
Were there any complications during labor or delivery?
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yes
no
Describe:
What was the mother's age at the time of delivery
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How many weeks gestation was the child born? (39 -40 weeks is considered full term)
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Child's height and weight at birth
How was the child delivered (vaginal/c section) if emergency c-section please indicate
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Any interventions provided in the hospital (CPAP, feeding, or follow up on concerns noted in pregnancy, etc.)
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Any hospital stay after birth (extended stay in recovery, NICU, etc)
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Medical History
HEARING - any concerns, history of ear infection, latest screening information:
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VISION - any concerns, history of concerns, latest screening information:
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Describe any pertinent information about the child's medical history/health status (surgeries, diagnoses) as well as when they were diagnosed and by whom:
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Check and Describe all that Apply
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Adenoidectomy
allergies
asthma
behavior issues
brain injury
breathing problems
cardiac issues
chicken pox
diabetes
ear infection
ear/PE tubes
Encephalitis
frequent colds
feeding/swallowing issue
high fever
hearing loss/difficulties
measles
meningitis
mumps
seizures
sinusitis
sensory difficulties
sleep issues
tongue tie
tonsilitis
tonsillectomy
traumatic brain injury
vision issues
Other
Describe conditions checked and or other information that is important to your child's health history:
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Is the child up to date on immunizations
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yes
no
Has the child ever had surgery?
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yes
no
Describe:
Has the child ever been hospitalized? (other than birth - if applicable)
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yes
no
Describe:
Has the child ever been in a serious accident?
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yes
no
Describe:
Does the child have a chronic illness?
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yes
no
Describe:
Please list any current medications, dosage and rationale
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Does the child use any specialized equipment (walker, communication device, hearing aid)
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yes
no
Describe:
Does the child receive other services
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occupational therapy
physical therapy
neurologist
developmental pediatrician
speech therapy (other company/school)
ABA/behavior
Educational Consultant
Psychologist
Vision
Other
Comments on any of the above selected services:
Developmental History
Activities of Daily Living
Describe your child's current status with each area below
Toilet Trained
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yes
no
emerging
Describe Toilet Training (example: trained during the day but pull ups at night, needs assist with wiping, occasional accident, etc.)
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Bathing
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no concerns
difficulty with hair washing
difficulty with getting their face wet
Describe Bathing Experience (example: difficulty with transition in/out of the bathroom, gets in the tub but will cry when bathed, etc)
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Dressing: Upper Body/Lower Body
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independently dressing self
independently undresses self
participating in dressing/undressing (presents arms when asked)
passively tolerates you dressing/undressing them
Resists dressing/undressing
Dressing: Socks + Shoes
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independent/no concern
emerging (explain below)
adult completes (explain below)
Which of the following CAN your child do?
buttons
Zippers
Tie shoes
Velcro straps
snaps
Describe Overall Dressing Experience (example: runs away when you present a shirt, removes clothing when home, texture preferences)
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Hair Care (washing, brushing, cutting)
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no concerns
tolerates
doesn't tolerate (explain below)
independent
Describe Hair Care Experience (example: refuses hair cuts, cries with hair brushing, etc).
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Tooth Brushing/Oral Care
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no concerns
tolerates
doesn't tolerate (explain below)
independent
Describe Tooth Brushing Experience (example: pulls away, gags, refuses, resists etc.)
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Motor Milestones
Please indicate age/range for the following:
Sitting unassisted
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Army Crawl
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Crawl
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Pull to Stand
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Walk
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Do you have comments in general about your child's motor development (on time, delayed, skipped or early)
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Speech/Language Milestones
Please indicate age/range for the following:
independent babbling (example: "ba ba ba")
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imitating specific sounds (example: you say "uh oh" and they copy you)
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imitation of words (example: "wa wa" for water, "mama" for mom, "dada" for dad)
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independent production of single words
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How many single words does your child say
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not yet producing words
5-20
21-50
51-100
101-150
151-300
301-500
501+
combining words (example: "want cookie")
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Does your child produce sentences of the following length:
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not yet producing words
2 words
3 words
4 words
5+ words
How does your child communicate their daily wants/needs
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hand leading (bringing you to the item)
bringing the item to you
crying/whining
gestures
combination of gestures/vocalizations
single words
phrases
behaviors - such as dropping to the ground, hitting, pushing, screaming etc.
independently meets their wants/needs - moves furniture to climb, opens fridge, etc.
no concerns - will ask for items and receive them without difficulty or independently obtains
Any Additional Comments:
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How much of your child's speech do you understand (25%, 50%, 75%, 100%)
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What percentage of your child's do members outside of your family understand?
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Feeding Milestones
Please indicate age/range for the following:
Breast-Fed
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Drinking from a bottle
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Drinking from a cup
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Comments on Drinking overall (bottle, open cup, sippy cup, straw cup)
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Using Utensils
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Comments on Utensil Use (fork, spoon, independent, accepting of help, etc.)
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Eating Table Food
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Does your child have any preferences for specific textures (solids, purees) /temperatures?
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Does your child have any food allergies?
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Does your child avoid/dislike certain foods?
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What are your child’s favorite foods?
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Behavior Milestones
Describe your child's general mood/behavior on a daily basis?
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Is your child frustrated by their communication/motor/sensory difficulties?
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Does your child have any difficulty with:
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attention
agression
answering simple questions
understanding others
excessive drooling
producing speech sounds
reading
remembering
transitions during the day
frustration tolerance
anger
answering wh- questions
following directions
chewing/eating
stuttering
school work
maintaining eye contact
word retrieval
Other
Sensory Experiences
Bright Lights/Visual Input
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seeks out/enjoys
avoids
no concerns
Sounds/Auditory Input
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seeks out/enjoys
avoids
no concerns
Touch/Tactile Input (messy play)
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enjoys
avoids
no concerns
Oral Input (mouthing, grinding teeth, licking, etc)
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seeks out/enjoys
avoids
no concerns
Movement/ Vestibular + Proprioceptive Input (big hugs, tickles, flipping, swings, slides, etc.)
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seeks out/enjoys
avoids
no concerns
Body Awareness (hunger, pain, bathroom, etc)
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aware
unaware
no concerns
Describe any Sensory Concerns/Preferences
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Educational History
Is your child currently enrolled in daycare/school
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yes
no
Name of the program
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Days/Times they attend
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Grade Level
Type of Classroom
Accommodations
Learning difficulties the child has faced: * if applicable
Social History
Who does the child interact with on a daily basis
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How does the child interact with family?
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How does the child interact with someone new?
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Does the child participate in community activities?
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Final Details :)
Child's Strengths
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Child's Weaknesses/Areas to Grow
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What are the child's favorite activities?
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How do the child's delays in their developmental skills impact the family?
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What are your expectations/goals for therapy as a whole?
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Is there anything else that is important for us to know about your child that will help us to get to know them better and better meet them where they are at and help bridge the gap with their communication skills?
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Please upload any other pertinent background documents/records
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Person Completing the Form
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First Name
Last Name
I acknowledge that this form will be utilized to assist the evaluating therapist complete the background section of the evaluation. I have provided as accurate information as possible to help guide the treatment of this child.
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