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  • Child Therapy Case History Form

  • Therapy Associates requests this information for the purpose of completing your child's evaluation.

    Completion of this form is required prior to your scheduled evaluation.

  • PATIENT INFORMATION

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  • Therapy Precautions

    (please list)

  • FAMILY HISTORY

  • Child Therapy Case History Form

    Page 2

  • Was labor and delivery normal? (please circle)

  • MEDICAL HISTORY

  • Has your child had any of the following? (please check all that apply)

  • Has your child received therapy anywhere else? (please circle)

  • Child Therapy Case History Form

    Page 3

  • THERAPY

    ...continued

  • GROWTH & DEVELOPMENT

  • Did your child reach developmental milestones at appropriate times? (If no, specify when age milestones were met)

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  • EDUCATIONAL HISTORY

  • **If applicable. please provide a copy of your child's most recent IEP**

  • Child Therapy Case History Form

    Page 4

  • SPEECH THERAPY

    COMMUNICATION HISTORY
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  • Child Therapy Case History Form

    Page 5

  • OCCUPATIONAL THERAPY

  • Please answer the following Yes/No questions.

  • Vision:

  • Gross / Fine Motor:

  • Functional Status:

  • Sensory:

  • SOCIAL BEHAVIOR

  • FEEDING SWALLOWING

  • Therapy Associates, Inc. 904 6th Ave Ct NE Isanti, MN 55040 Phone (763)444.8700Fax: (763)434.0192

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