MYO Therapy Case History Form

MYO Therapy Case History
6700 Woodway Dr., Woodway, TX 76712

Phone: 254-246-4713 Fax: 254-647-0365
MYO 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. If you are not sure of a particular answer, please place a question mark after it. Thank you.
Date

MonthDayYear
Date
Person Completing Form
Relationship to Child
Last
First
Middle
Date of Birth

MonthDayYear
Date
Sex
Street
Address
City
State
Zip
Telephone(s)
Email Address
example@example.com
Child's Pediatrician (PCP)
Fax
Fax
Briefly describe your child's problem
When was the problem first noticed?
What has been done about it?
FAMILY HISTORY
FATHER'S Name
Date of Birth

MonthDayYear
Date
Occupation
Place of Employment
Work/Cell Phone
MOTHER'S Name
Date of Birth

MonthDayYear
Date
Occupation
Place of Employment
Work/Cell Phone
PRENATAL & BIRTH HISTORY
How long was pregnancy?
How was mother's general health during pregnancy?
Any problems with pregnancy or delivery?
What was birth weight?
Did the infant have any of the following? (Check all that apply)

Breathing problemsOxygen givenNICU stayHeart problemJaundiceDefect of Ear/Nose/Throat/MouthParalysisSeizuresAntibiotics
Emergency C section?
Any problems with feeding? (Sucking/Swallowing?)
Use of Feeding (NG) tube?
Any other problems/birth defects?
Please describe briefly:
HEALTH & DEVELOPMENTAL HISTORY
Is the child currently taking any medications? Please list.
Does the child have any known allergies?
Please list
Has the child had any major surgeries?
What was infant's health during first month?

GoodFairPoor
Has the child had: (Check all that apply)

Frequent coldsEar infectionsAsthmaVision problemsPhysical HandicapEpilepsy/SeizuresAttention Deficit DisorderTraumatic brain injuryDrug allergies
Has the child had any other serious illness, accident or injury?
If so, briefly describe where and what happened?
Did the child meet all developmental stages on time? (ex. Sitting, Crawling, Walking, Feeding Self)? Yes or No?
If not, please describe:
Does the child have/show any of the following behaivors: (check all that apply)

Demands attentionShort attention spanNervous or sensitiveEasily frustratedProfits from disciplineOverly sensitive to loud noisesDifficulty playing/interacting with peersLacks confidenceHyperactiveWithdrawnTires easilyAggressivePrefers to play aloneMakes inappropriate statements
MYO HISTORY
Name of Dentist
Orthodontist
Pediatrician
Referred By
Was child breast fed?
Until what age?
Was child bottle fed?
Age Started?
Until what age?
Did child suck thumb or fingers?
Until what age?
Used pacifier?
Until what age?
Tongue sucking or tongue chewing?
Nail or Cuticle Biter?
Chews on pencils, knuckles, blankets?
Licks lips excessively?
Lip or cheek biting?
Is child a noisy eater?
How is Child's general health?
Is child a mouth breather? If so, During day, during night, or both?
Any Temporomandibular Joint (TMJ) problems?
Any history of frequent middle ear infections?
Have tonsils & adenoids been checked recently?
By whom?
If so, what was the doctor's opinion?
Does child have seasonal allergies?
If so, how treated?
Sinus problems?
If so, how treated?
Asthma?
If so, how treated?
Chronic upper respiratory infections/colds?
Has child ever had tongue thrust therapy?
If so, was therapy successful?
Did child ever have a speech problem?
Describe:
Has child ever had speech therapy?
For what problem and for how long?
Has child had orthodontic work in the past?
Is palate expansion being discussed?
If currently in braces, when were they applied?
Does child wear a retainer?
For how long?
Is there any other information you feel would help us evaluate your child?
ADDITIONAL COMMENTS/OTHER IMPORTANT INFORMATION
Should be Empty:

MYO Therapy Case History

MYO THERAPY CASE HISTORY FORM

FAMILY HISTORY

PRENATAL & BIRTH HISTORY

MYO HISTORY