Child Case History Form

Date *

Month Day Year
Date
Patient Name *
Name Parent #1 Name Parent #2

Name Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Age *
What is the reason for today's visit? *
What are your main concerns?
What are your goals for this evaluation/treatment?

Pregnancy/Birth History
Prenatal Care

Received Not Received
Pregnancy Proceeded

Without Complications With Complications
Describe Complications
Length of Pregnancy: (in weeks)
Delivery Method

Vaginal C-Section Emergency C-Section
Delivery Proceeded

Without Complications With Complications
Describe Complications
Mother's age at time of birth
Birth Hospital
Length of Child's hospital stay
Birth Weight
Birth Length
Complications Following Birth (If applicable):
Additional Comments

Medical History
Referring Physician
Phone
Pediatrician
Phone
Medical Diagnosis: (if applicable)
Does your child see a specialist (if so, provide providers name and purpose)
Hearing Test Last Test Date

Month Day Year
Date
Hearing Test

Never Tested Normal Test Results Abnormal Test Results
If abnormal test results please explain:
Vision Test Last Test Date

Month Day Year
Date
Vision Test

Never Tested Normal Test Results Abnormal Test Results
If abnormal test results please explain:
Surgeries/Procedures: List date, surgery/procedure, results/details
Other Medical Conditions

Medications/Allergies
Is your child on any medications? (please list all current medications)
Does your child have any allergies?
Daily Routines
Daycare/School Name
Teacher
Grade
Does your child receive any therapy services at school or have an IEP? (Please list all current/past therapies)
How often does your child receive therapy?
What are your child's therapist(s) names?
Does your child have any behaviors at school? (explain)

Questions/Concerns
Do you have any other questions or concerns?
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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