Case History Form
www.hollandpediatric.com
Personal Information
Child's Name
First Name
Last Name
Child Date of Birth
-
Month
-
Day
Year
Date
Child's Sex
Male
Female
Other
Parent's Name
First Name
Last Name
Day Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
How did you hear about our clinic?
Child lives with
Birth Parents
Adoptive Parents
Foster Parents
Parent & Step-Parent
One Parent
Other
Other Children in the Family?
Yes
No
Name
First Name
Last Name
Child's Sex
Male
Female
Other
Grade
Please Select
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Age 18+
Age
Any speech-hearing problem?
Yes
No
Is there a language, other than English, spoken in the home?
Yes
No
Which language?
Does the child speak the language?
Yes
No
Does the child understand the language?
Yes
No
Which language does the Child prefer to speak?
Has your child received any other evaluation or therapy for speech and language?
Yes
No
Where and for how long?
Has your child received any other evaluation for occupational therapy?
Yes
No
Where and for how long?
Please provide any previous evaluations, IEP reports or other documents.
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Has your child received any other evaluation or therapies (physical therapy, psychological, etc.)
Yes
No
Please describe
Do you feel your child has a speech problem?
Yes
No
Please describe
Has your child’s hearing been tested?
Yes
No
Where and what were the results?
Is your child aware of, or frustrated by, any speech-language difficulties?
Yes
No
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Birth History
How old was the mother when the child was born?
Was the child born at full-term?
Yes
No
How many weeks gestation
What did the child weigh at birth?
Did mother take any medication while pregnant?
Yes
No
What medications?
Did mother take non-prescribed drugs or alcohol during the pregnancy?
Yes
No
Were there any unusual conditions or complications about the pregnancy or delivery?
Yes
No
Please describe
If the child did not go home from the hospital with his/her mother, please describe why and how long before he/she was released.
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Medical History
Is your child currently under a physician's care?
Yes
No
Physician's Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Has your child had any of the following:
adenoidectomy
allergies
chicken pox
colds
ear infections
breathing difficulties
encephalitis
flu
head injury
high fever
measles
meningitis
mumps
ear tubes
seizures
sinusitis
sleeping difficulties
thumb/finger sucking
tonsillectomy
tonsillitis
vision problems
scarlet fever
Allergy type:
How frequent are ear infections?
Other serious injury, illness, or hospitalization?
Please list any medications that your child takes regularly:
Developmental History
Please indicate the approximate age at which your child achieved the following milestones:
Sat alone
Grasped crayon/pencil
Babbled
Said first word
Put 2 words together
Spoke in short sentences
Walked
Crawled
Toilet trained (night time)
Toilet trained (daytime)
Does your child...
choke on food or liquids?
put toys/objects in his/her mouth?
brush his/her teeth, or allowed brushing?
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Current Speech-Language-Hearing
Select any that apply
Does your child…
repeat sounds, words, phrases over and over?
understand what you are saying?
point to common objects/pictures on request?
follow simple directions? (“Get your shoes.”)
respond correctly to yes/no questions?
respond correctly to yes/no questions?
How does your child currently communicate basic needs or desires?
pulling others towards desired objects
pointing
vocalizing (grunts, vowels, whines)
single words
2-4 word sentences
sentences longer than 4 words
Other
Behavioral characteristics
cooperative
attentive
willing to try new activities
separation difficulties
easily frustrated
stubborn
leader
restless
poor eye contact
easily distracted
shy and withdrawn
impulsive
self-abusive behavior
inappropriate behavior
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Current Occupational Activities
Does your child attend extracurricular activities regularly?
Yes
No
What activities?
What are your child’s favorite toys and activities?
Do you have any concerns related to your child’s motor development, sensory processing, attending or behavior?
Yes
No
What are your concerns?
Does your child display any strong aversion to food types?
Yes
No
Does your child suck on hair, clothing, blanket, etc?
Yes
No
Does your child enjoy taking a bath?
Yes
No
Swings?
Yes
No
Parties?
Yes
No
Does your child resist brushing their teeth?
Yes
No
Is your child sensitive to loud sounds?
Yes
No
Is your child sensitive to loud sounds?
Yes
No
Bright lights?
Yes
No
Tags in clothes?
Yes
No
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Full Name
First name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Submit
School History
Is your child in school yet?
Yes
No
School Name
Grade
Has your child repeated any grades?
Yes
No
Which grade?
Should be Empty: