Client History Profile
Name of client
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Who is filling out this profile?
client
guardian
parent
spouse
Other
How did you hear about Hand in Hand: Resources and Consulting/ who recommended us to you?
General Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Client date of birth:
-
Month
-
Day
Year
Date
Client gender:
Female
Male
Client approximate height:
Client approximate weight:
Client's current educational placement:
public school
private school
university model
home school
Other
If client is enrolled in school indicate grade level or year of university:
If client is employed indicate type and place of employment:
If client is married indicate spouse's full name:
If client is a minor indicate father's name:
Father's Phone Number
-
Area Code
Phone Number
Father's Email
example@example.com
If father is not living in the same home as a minor client indicate where/distance from client's home.
Father's occupation:
If client is a minor indicate mother's name:
Mother's Phone Number
-
Area Code
Phone Number
Mother's Email
example@example.com
If mother is not living in the same home as minor client indicate where/distance from client's home.
Mother's occupation:
Any secondary address for either parent:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client lives with:
parent(s)
self/alone
step parent
non family
spouse
other
History
Was the client adopted?
yes
no
If the client was adopted indicate at what age and from what country:
If known - how long was the client with his/her biological parent(s)?
Describe what kind(s) of living situations the client lived in before adoption and for how long in each: (foster care? residential children's home? orphanage?)
Father's Date of Birth
-
Month
-
Day
Year
Date
Father's highest level of education:
Mother's Date of Birth
-
Month
-
Day
Year
Date
Mother's highest level of education:
Client's Medical History - Birth to Present
Length of pregnancy:
Birth weight:
Apgar Scores:
Client's birth:
vaginal
C-section
vacuum extraction
forceps
vaginal birth after C-section
Please describe any complications of mother or child during pregnancy or childbirth:
At what age did you notice non- typical development and what were those observations?
Indicate client's IQ:
Indicate any labels or classifications given to the client and what type of professional diagnosed the client.
Please list any other medical, neurological, visual, hearing therapeutic, psychological or educational assessments of the client. Indicate dates, diagnosis and examiner.
Has the client ever experienced a head injury? If so, please elaborate, include age of injury.
Has the client ever broken a bone? If so, please indicate which bone and at what age.
Please describe any concerns of client's organs, including skin.
Does the client experience head aches? If so, please indicate frequency, duration, treatment and location - back of the head, front, behind the eyes, etc.
Has the client ever had surgery? If so, please indicate type, age at event and outcomes.
Does the client have any medical condition which limits physical activity? Explain if so.
Indicate any medical specialist the client is currently seeing:
nutritionist
vision therapist
speech therapist
music therapist
chiropractor
OT
PT
cardiologist
psychiatrist
psychologist
counselor
neurologist
Other
List and describe any medical testing the client has experienced, at what age, and results. (MRI, CT scan, lumbar puncture/spinal tap, blood test, etc)
If the client has had any seizures, indicate the age(s) of occurance, frequency, length and type of seizure activity:
If applicable, list the type and current dosage of seizure medications:
List any other medications the client is taking as well as the dosage and how long the client has been taking the medications:
Please indicate any dietary supplements and/or vitamins the client is taking:
List any allergies, the age the allergies first became apparent, and if the allergy is food related, chemical or enviromental:
Please indicate if the client has had strep throat, how many times it has occurred and at what age:
Please describe any other health concerns the client may be experiencing:
Describe the client's activity level including sports and exercise. Include the frequency and duration of any physical activity as well as the type of activities:
Has the client ever hiked 3 miles?
yes
no
Has the client ever run a mile without stopping?
yes
no
Indicate the client's usual sleep times. (example 8:30pm to 7:00am)
Does the client sleep with his/her mouth open?
yes
no
unknown
occasionally
Does the client snore or breath so heavily you hear him/her?
yes
no
unknown
occasionally
Visual Information
Has the client has a recent eye exam - within the past year?
yes
no
Approx date of exam:
Does the client have 20/20 acuity?
yes
no
unknown
Indicate prescription of eye glasses or contact lenses:
Has the client been diagnosed with any of these conditions?
nearsighted
farsighted
Strabismus
Astigmatism
Glaucoma
Nystagmus
Cortical blindness
Irlen Syndrome
Amblyopia
Macular issues
Cataracts
Blindness
Color blindness
Other
Indicate areas of concern in regards to writing:
letter reversals
mirror writing
writing on a line
avoidance of copy work
difficulty copying from white/black board
Other
Indicate areas of visual concern in regards to reading:
frequent loss of place
failure to recognize the same word in the next sentence
complaints of hurting eyes or headaches while reading
sees words or letters doubled or blurred
holds reading material very close to the face
confuses similar words
rubs eyes frequently
eyes tear/water while reading
struggles/avoids/dislikes to read
poor spelling
Other
If the client has ever received vision therapy please indicate at what age, duration, outcomes.
Does the client make good/appropriate eye contact with others?
yes
no
culturally appropriate
Auditory Information
Please indicate auditory testing done and any diagnoses received. Include dates and summarize results. If possible, bring copies of the results with you to the initial evaluation.
Please indicate and summarize frequency of client's colds and/or sinus infections/congestion.
Please indicate and summarize frequency of client's ear infections. At what age(s) and what medications, if any, were administered.
If the client has experience hearing loss, indicate the age the loss occurred, which ear(s) were affected, the decibel range (if known) and the cause of the hearing loss.
Does the client experience tinnitus (perception of noise or ringing in the ears)?
yes
no
If yes, indicate the age of onset, which ears were affected as well as any family history of tinnitus.
Do you consider the client overly sensitive to sounds?
yes
no
If yes, please indicate the age of the client when this was first observed as well as the past and current severity of symptoms:
Does the client experience tonal processing issues and/or often misinterprets words spoken to him/her?
yes
no
If yes, please give examples:
Has the client received any Tomatis, AIT, AET, SHS, Listening Program, and / or Samonas auditory training?
yes
no
If yes, please indicate the forms of auditory training with the dates and results:
Does the client experience physical tics (involuntary movements) or fears/phobias?
yes
no
If yes, please give examples:
If the client listens to music list approximate length of listening per day and type of music most frequently experienced during listening hours.
Please indicate all areas of concern:
short attention span
difficulty following verbal instructions
easily distracted
forgetful
Dietary Information
Was the client nursed by biological mother?
yes
no
unknown
At what age was the client weaned?
If the client was not nursed please indicate what brand of formula was used.
At what age were solid foods added to the client's diet?
Please list any type of nutritional testing (blood analysis, hair analysis, urine analysis...) the client has had done and summarize the results:
Please describe the client's current diet: (summarize the usual breakfast, lunch and dinner the client consumes daily)
Not including drinks mixed with water or juices, how many ounces of water does the client drink each day?
Please choose the most appropriate option for the client's consumption:
excessive
daily
weekly
rarely
never
water
fruit juices
caffeine/energy/soft drinks
sugar/candy/desserts
pasty/cereal/starches
white flour
dairy products
fruits/Juice Plus+
vegetables (not starchy)
meats/eggs/protein shakes
whole grains/breads
artificial colorings
artificial sweetners
tobacco
alcohol
Please choose the most appropriate level of concern:
No concern
mild concern
concerned
moderately concerned
very concerned
physical endurance
coordination
balance
crawling
walking
running
weak
physical activity level
runs into walls/people
spills liquids often
muscle tone high/low
fine motor
left/right confusion
bed wetting
daytime incontenence
sucks thumb/fingers
overly ticklish
sensitive to clothing tags/seams
overly sensitive to sunlight
overly sensitive to pain
overreacts to small injuries
bites fingernails/toenails
falls out of chairs
lack of processing/timing
does not feel hunger
does not feel full when eating
does not react when hurt
not able to identify where/when bruises happened
overly rough when playing/frequently unintentionally hurts others
hugs too hard
constantly in the 'personal space' of others
inability to NOT touch the food/belongings/bodies of others
haircuts are difficult
troubles with washing and/or brushing hair
unaware of outdoor temperature/wears inappropriate clothing for weather
temperature of shower or bath water too hot or cold
tics
poor appetite
picky eater
over eating
anorexia/bulimia
gag reflex
food cravings
overly sensitive to food odors
overly sensitive to food textures
overly sensitive to food tastes
does not notice offensive odors
picky about food temperatures
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Include any additional information that you think SHOULD have been listed in this section and wasn't that you want us to be aware of:
Name several foods the client consistently refuses:
If given a choice what would the client eat every day:
Developmental Information
Please indicate the age in months and years when the following developmental steps were achieved as well as any comments about that stage of development:
Crawled on stomach:
Crept on hand and knees:
Walked:
Potty trained:
First word:
First couplets - two words together:
Three or four word phrases:
Sentences:
Conversations:
Initial word recognition/reading:
Please indicate if the client enjoys the following activities and the amount of time spent on each activity daily:
Watching television:
Computer time other than school work:
Video games:
Looking at/reading books:
Being read aloud to:
Language Information
Please describe any concerns about the client's language abilities:
Please indicate concern in any of the following areas:
stammering
stuttering
drooling
Aphasia
difficulty chewing
mouth breathing
tongue placement
teeth/dental concerns
Indicate any concerns with the client's articulation (making specific sounds correctly):
If the client uses American Sign Language indicate fluency.
If the client speaks languages in addition to English please indicate which languages and the level of fluency in each.
Manual Information
Please indicate all areas of concern:
tying shoes
buttons/zippers/snaps
pencil grasp unusual
sloppy handwriting
jar lids/cans/bags
If the client types indicate the ability to use all fingers, knowledge of 'home keys' and words per minute.
Does the client print both upper and lower case letters?
yes
no
Does the client write in cursive?
yes
no
just learning
Please indicate whether the client uses right/left or either/both for each of the following activities:
Right hand
Left hand
Both hands
writing
eating
throwing
sports
drawing/coloring
brushing/combing hair
brushing teeth
Did this client have difficulty/take a long time choosing a dominate hand?
yes
no
still not clear
Have you ever thought this client should be using the other hand? If so, what were your concerns?
Was the client encouraged to use one hand over the other at an early age - before age 7? Explain if so.
If this client is an identical twin please indicate which is the dominate hand for him/her.
Are any of the following people (who are biologically related to the client) either left-handed or considered to be ambidextrous?
mother
father
siblings
grandparents
aunts
uncles
first cousins
Academic Information
Please indicate concerns in any of the following areas:
poor at testing
reading comprehension
math word problems
math computation
reading
math fact
math concepts
logical thinking
Rate math fact mastery as good, average, poor or not introduced for the following operations:
good
average
poor
not yet introduced
addition
subtraction
multiplication
division
Please list all schools/programs attended (including dates, grades and degrees). If home schooled, please list curriculum used:
Please list any learning labels or classifications given to the client:
What, if any, extracurricular activities, sports or lessons does the client participate in:
Behavioral Information
Please indicate the level of concern for each area:
no concern
mild concern
concerned
moderate concerned
very concerned
hyperactive
hypoactive (low activity level)
impulsive
explosive temper
anger (non explosive)
low frustration level
temper tantrums
destructive behavior
aggressive behavior
cyclical behavior (good days/bad days)
academic output ( good days/bad days)
generally overly sensitive
perseveration
follow through
avoidance behavior
difficulty with parents
difficulty with siblings
difficulty with teachers
difficulty with peers
competative
socially immature
few or no friends
emotional/overreacts
social
complient
cooperative
obedient
perfectionist
disorganized
flexible
inflexible/rigid
poor judge of time
desire to withdraw
suicidal
high achievement
low achievement
Describe any emotional or behavioral difficulties of the client:
Describe any notable positive or negative behaviors of the client:
Goals and Desired Outcomes
Please list behavior goals and expectations:
What are your academic goals and expectations?
Please indicate who will be working with the client and the amount of time each day (5 days a week) available:
Please add any further information which you believe would give us a more complete picture of the client.
Anything you want to ask before we see one another or speak on the phone again?
Please attach a family photo.
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