Child Case History Form

Today's Date*

MonthDayYear
Date
Patient Name*
Child's Gender*

MaleFemale
Patient Date of Birth*

MonthDayYear
Date
Age*
Name Parent #1 Name Parent #2*

NameName
Guardian/Foster Care.

Legal GuardianFoster Parent
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell/Other Number*
Please enter a valid phone number.
What is the reason for visit?*
What are your main concerns?*
What are your goals for this evaluation/treatment?

Pregnancy/Birth History
Prenatal Care

ReceivedNot Received
Pregnancy Proceeded

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

VaginalC-SectionEmergency C-Section
Delivery Proceeded

Without ComplicationsWith 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
Pediatrician's Name/Practice Name
Phone
Referring Physician's Name/Practice Name
Phone
Medical Diagnosis: (if applicable)
Does your child see a specialist (if so, provide providers name and purpose)
Hearing Test Last Test Date

MonthDayYear
Date
Hearing Test

Never TestedNormal Test ResultsAbnormal Test Results
If abnormal test results please explain:
Vision Test Last Test Date

MonthDayYear
Date
Vision Test

Never TestedNormal Test ResultsAbnormal 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's Name
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*

MonthDayYear
Date
Should be Empty: