KS-Case History Form

Case History Form
Child's Full Name
Date of Birth

MonthDayYear
Date
Gender at Birth:

MF
Home Address
Apt
City
State
Zip Code
Parent 1 Name

First NameLast Name
Phone: (H)
Cell:
Address same as child

YesNo (Please complete below)
Home Address
Apt
City
State
Zip Code
Parent 1 - Social Security Number
Parent 1 - Date of Birth

MonthDayYear
Date
Parent 1 - Employment Status

Full TimePart TimeNoneStudent
Parent 1 Email address
example@example.com
Parent 2 Name

First NameLast Name
Phone: (H)
Cell:
Address same as child

YesNo (Please complete below)
Home Address
Apt
City
State
Zip Code
Parent 2 - Social Security Number
Parent 2 - Date of Birth

MonthDayYear
Date
Parent 2 - Employment Status

Full TimePart TimeNoneStudent
Parent 2 Email address
example@example.com
Legal Guardian (if other than parent)

First NameLast Name
Phone: (H)
Cell:
Address same as child

YesNo (Please complete below)
Home Address
Apt
City
State
Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
Employment Status

Full TimePart TimeNoneStudent
Legal Guardian Email address
example@example.com
Please list individuals who live in the home with your child:
Name/Age /Relationship to Child
Name/Age /Relationship to Child
Name/Age /Relationship to Child
Name/Age /Relationship to Child
Is there any history of speech/language gross motor, fine motor, learning. or developmental problems among immediate family members:

YesNo
If yes, please explain
Pediatrician's Name
Practice/Office Name
Pediatrician's Location/Address
Pediatrician's Phone
Fax number
Has your child's pediatrician expressed concerns regarding your child's development?

YesNo
If yes, please explain
Who referred you to Kidspeak?

DoctorFamily MemberSchoolSelfOther
Medical History
Length of pregnancy:
Complications during pregnancy:

YesNo
If yes, please explain
Complications at birth/delivery:

YesNo
If yes, please explain
In NICU:

YesNo
If yes, please list how long and reason for stay:
Does your child have a history of, or currently have any of the following: Please mark all that apply.

Ear InfectionsPermanent Hearing LossPE Tubes (tubes in ears)Tonsils removedAdenoids removedTongue tie current/repairedCheek tie current/repairedLip tie current/repairedCleft palate current/repairedSensory processing disorderAllergiesHistory of seizuresCritical illnessHospitalizations/SurgeriesPremature BirthAutismDevelopmental DelayDown SyndromeFeeding/Swallowing issuesMotor delayOther
For any marked above, please provide further information to explain:(ex: when? how?)
Does your child have any previous OR current diagnosis and/or syndrome(s)?

YesNo
If yes, please explain
Is your child currently or previously under the care of a specialist (ex: Developmental pediatrician, Neurologist, Psychiatrist, ENT, etc)? (If yes, please list below*)

YesNo
Specialist Name
Office phone
Office address
Date of last visit

MonthDayYear
Date
Specialist Name
Office phone
Office address
Date of last visit

MonthDayYear
Date
OTHER
Please list all current medications that your child is taking and for what reason
Time your child goes to sleep
Time your child wakes up
Comments about your child's sleep (if applicable)
Please indicate if your child does any of the following: Please mark all that apply.

Uses pacifier/sucks fingers or thumbDrinks from an open cupUses a spoon/forkGag, choke, or vomit with any foodsEats table foodDrinks from a straw/water bottleEats a variety of foods
Developmental Milestones: To the best of your ability, please give the approximate age when your child was first able to do the following activities (relevant to his/her age):

If your child is not yet doing these activities, please write "not yet" under the AGE column

Activity:

	Child's Age (In Months)
Rolling Over
Sitting Alone
Babbling
Crawling on Hands and Knees
Standing Alone
Walking Independently
Running
Finger Feeding Self
Spoon Feeding Self
Eating Solid Foods
Toilet Trained
Dressing Self
Walking Up Stairs Independently
Tricycle
2-Wheel Bike
Using Single Words
Combining Words
Naming Simple Objects
Asking/Answering Simple Questions
Engaging in Conversation

What are your child's strengths?
What are activities/toys that your child enjoys?
Communication Skills
How does your child communicate at this time? Please circle all that apply:

Sign LanguageSingle WordsGestures or Pointing2-3 Word PhrasesSounds/Babbling4+ Word SentencesGruntingOther
Does your child use alternative/augmentative communication (AAC) devices?

YesNo
Please explain
Educational History
Child's current educational placement:

HomeDaycare/School
If in preschool/daycare, how many days per week and hours per day?
School
Days in attendance
School start/end times
Current grade
Teacher's name
Has your child repeated a grade (ex: repeated kindergarten for a second year)?

YesNo
If yes, please explain
Does your child have an IEP/IFSP Yes No If yes, what services are listed on the IEP:
Does your child have an IEP/IFSP?

YesNo
If yes, what services are listed on the IEP?
PLEASE BRING COPIES OF YOUR CHILD'S IEP/IFSP and EVALUATIONS

Current OR previous therapies (school and/or clinic).

	Dates:	Location:
Speech Therapy
Occupational Therapy (OT)
Physical Therapy (PT)
ABA
Counseling
Other

Current Concerns
Please describe your concerns today
When was the problem first noticed?
By whom?
What do you hope we can accomplish in therapy?
Please indicate any/all concerns you have for your child's development: (Mark all that apply).

Speech is not understood by family membersEasily distracted/short attentionSpeech is not understood by others outside the familyDifficulty answering questionsLimited (expressive) vocabularyLimited diet/eating difficultiesNot interested in peers/prefers to play aloneSeparation difficultiesEasily frustrated/impulsiveDelays in fine motor skills (hands, fingers)Delays in gross motor skills (walking, running, climbing, jumping)Sensory differencesNot speaking in full sentencesDelayed social skillsDifficulty following directionsDifficulty with transitionsDestructive/aggressiveWithdrawnStutteringSelf-injurious behavior
Please include any additional information you would like to provide to help us better understand your child
Thank you for your assistance in completing this form. This information is confidential and will be used strictly for therapeutic purposes.
Person Completing this Form: *
Relationship to Child:*
Signature*
Date*

MonthDayYear
Date
Should be Empty: