Child Case History Form
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  • Child Therapy Case History Form

  • Therapy Associates requests this information for the purpose of completing your child's evaluation.

    Completion of this form is required prior to your scheduled evaluation.

  • PATIENT INFORMATION

  • Today's Date:
     / /
  • Has your child been diagnosed by a physician?
  • What services are you here for? (check all that apply)
  • What are your main concerns? (check all that apply)

  • Therapy Precautions

    (please list)

  • FAMILY HISTORY

  • Parent's Marital Status:
  • Is the child adopted?
  • Have there been any of the following in your immediate or extended family?

  • Child Therapy Case History Form

    Page 2
  • Were there complications during your pregnancy?
  • Was the pregnancy full-term?
  • Were any drugs or medications taken during the pregnancy?

  • Was labor and delivery normal? (please circle)

  • Was labor and delivery normal?

  • MEDICAL HISTORY

  • Has your child had any of the following? (please check all that apply)

  • Has your child received therapy anywhere else? (please circle)

  • Has your child ever received therapy anywhere else?

  • Child Therapy Case History Form

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  • THERAPY

    ...continued

  • GROWTH & DEVELOPMENT

  • Did your child reach developmental milestones at appropriate times? (If no, specify when age milestones were met)

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  • EDUCATIONAL HISTORY

  • May we communicate with the school therapist?

  • **If applicable. please provide a copy of your child's most recent IEP**

  • How do you perceive your child's academic skills?
  • How do you perceive your child's intelligence relative to other children their age?
  • How do you perceive your child's social maturity?

  • Child Therapy Case History Form

    Page 4

  • SPEECH THERAPY

    COMMUNICATION HISTORY
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  • Child Therapy Case History Form

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  • OCCUPATIONAL THERAPY

  • Please answer the following Yes/No questions.

  • Vision:

  • Rubs eyes while working
  • Poor reading comprehension
  • Eyes are tired at end of day
  • Trouble copying from board
  • Holds things very close to eyes
  • Complains of eyestrain, headaches
  • Makes reversals when copying or reading

  • Gross / Fine Motor:

  • Established hand preference
  • Gets tired easily playing or writing
  • Seems generally weak compared to others
  • Has difficulty playing on playground
  • Seems clumsy awkward
  • Has poor ball skills (catching, dribbling)
  • Has poor handwriting skills
  • Has difficulty with buttons and zippers

  • Functional Status:

  • Independent with dressing
  • Independent with toileting
  • Independent with grooming
  • Independent with bathing/showering
  • Independent with self-feeding
  • Can independently fix a snack

  • Sensory:

  • Avoid balancing activities
  • Engaging in frequent spinning, jumping
  • Dislike and avoid messy play
  • Has difficulty manipulating small objects
  • Seek deep pressure, squeezing in furniture, crashing, banging
  • Becomes upset with loud noises
  • Dislike strong smells or taste

  • SOCIAL BEHAVIOR

  • FEEDING SWALLOWING

  • Therapy Associates, Inc. 904 6th Ave Ct NE Isanti, MN 55040 Phone (763)444.8700Fax: (763)434.0192

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