Case History Form

Metropolitan Milestones Therapy

1744 Bethlehem Church Rd.

Reidsville, NC, 27320

Liz@mmtpllc.com

(336) 613 223

Patient Name*

First Name Last Name

Date of Birth*

Day Month Year

MID*

Physician Name/Location*

Describe birth history (weeks’ gestation, birth weight, vaginal/cesarean, prenatal complications, birth complications, etc.) *

With whom does your child live (siblings, etc.) *

Is your child taking any medications? *

Has your child been hospitalized or had any major surgeries? If yes, explain. *

How old was your child when he/she met the following developmental milestones?*

_____ crawl ______ walk _____ first words __________ toileting

Is there a history of any of chronic ear infections:*

YesNo

Is there a prior history of therapy? (CDSA, speech, physical, occupational)*

Are there any speech/language deficits in the family?*

What are your concerns regarding your child’s speech/language development? Please explain. We will use these concerns as a base for the targeted goals set for the first authorization period.*