Occupational Therapy Case History Form

OCCUPATIONAL THERAPY CASE HISTORY FORM
All of the following information is for the use of Central Texas Therapy Spot’s professional staff and will be handled in confidence.

This information will assist the staff in completing a meaningful examination. Please answer the questions as fully and accurately as possible. Thank you.
Name of Responsible Party filling out this questionnaire*

First NameLast Name
Relationship to Child:*
Child's Doctor:
Do you want a copy of our report sent to the pediatrician?

YesNo
To what other professional persons or agencies do you want a report sent (please provide name/address)?
Who can we thank for telling you about our practice?
IDENTIFYING INFORMATION
Child's Name:*

First NameLast Name
Nickname:
Date of Birth:*

MonthDayYear
Date
Age:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent's Name:*

First NameLast Name
Home / Cell Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Email Address:*
example@example.com

STATEMENT OF THE PROBLEM
Describe what problem(s) your child is having with motor development, sensory processing,or behavior:
Does your child have any speech, language or hearing disorders or challenges?

YesNo
If yes, please describe:
List any other concerns you have regarding your child’s development:
Does your child have a formal diagnosis?

YesNo
If yes, when was it made and by whom?

FAMILY HISTORY
Parent 1:

First NameLast Name
Parent 1 Occupation:
Parent 1- Date of birth

MonthDayYear
Date
Email
example@example.com
Parent 2:

First NameLast Name
Parent 2 Occupation:
Parent 2- Date of birth:

MonthDayYear
Date
Email
example@example.com
Other children in the family (Names & Ages):
Have any members of your immediate family been diagnosed with any of the following:

(Please indicate FATHER, MOTHER, or SIBLING)
Learning Disability
Dyslexia
Speech and language delay/disorder
Sensory processing disorder
Auditory processing disorder
ADD/ADHD
Autistic spectrum disorder/PDD
Hypotonia
Delayed motor skill development
Other
Please explain:

IDENTIFYING INFORMATION