Pediatric Case History Form

single married divorced separated widowed Other

yes no

yes no

yes no

yes no

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

yes no

yes no

yes no

yes no

yes no

yes no

occupational therapy physical therapy neurologist developmental pediatrician speech therapy (other company/school) ABA/behavior Educational Consultant Psychologist Vision Other

choke on liquids choke on foods avoid foods maintain a special diet suck thumb/pacifier use a bottle after 1 year mouth objects

0-20 21-50 51-100 101-150 151-300 301-500 501+

2 words 3 words 4 words 5+ words

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

yes no