Pediatric Case History Form
Patient Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
School
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Grade
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IEP
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Yes
No
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian(s) Name:
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First Name
Last Name
Home Phone
*
-
Area Code
Phone Number
Cell Phone
*
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Area Code
Phone Number
Email
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Child's Pediatrician
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Has Child Had Speech, Physical and/or Occupational Therapy In The Past?
*
Other Providers Seen For This Condition:
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Child's Birth History and Development
Were there any complications, illnesses or injuries during pregnancy?
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Were any medications taken during pregnancy or delivery?
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Was the pregnancy full term? If no, how many weeks:
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Birth Weight
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Delivered Via
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Vaginal
C-Section
Why was the c-section performed?
Emergency
Failure to Progress
Breech
Transverse
Planned/Scheduled
Were forceps or a vacuum used?
Yes
No
Were there any complications during delivery?
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Jaundice
Transfusions
Breathing Difficulty
Feeding Difficulty
Angar Score
Describe any congenital defects:
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As an infant did the child seem:
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Happy
Cried often
Slept long hours
Woke often
Slow feedings
Ate well
Difficult to soothe
Difficult to hold/cuddle
Difficult to get to sleep
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Medical History
Please Check The Following As They Apply To Your Child:
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Asthma
Frequent High Fevers
Allergies
ADD/ADHD
Bronchitis
Kidney Disease
Cardiac
Cancer
Chronic Colds
Tonsillectomy
Convulsions
Meningitis
Reflux
Whopping Cough/Croup
Ear Infections
Hypertension
Hay Fever
Diabetes
Seizures
None Of The Above
Has your child ever had a blow to the head? Did he/she lose consciousness?
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Does your child have dietary restrictions?
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Describe any other illnesses, injuries, operations or physical problems not mentioned above:
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Has your child ever had a psychiatric, developmental, neurological or EEG/MRI evaluation? If so, why and what were the results:
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Educational History
Does your child attend daycare/preschool? Where:
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If your child attends school (grades K-12) please describe his/her overall performance:
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Does your child get along with others in school/daycare/preschool:
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Provide the age your child was able to complete the activity.
Held Up Head Alone
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Sat Alone
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Stood Alone
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Fed Self With Spoon
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Independently Dressed
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Said First Word
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Rolled Over Alone
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Crawled
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Walked Unaided
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Potty Trained
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Drink Only From Cup
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Combined Words
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Are there any specific questions you have about your child that you would like us to try to address during the assessment?
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What are your goals for therapy?
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Developmental Questionnaire
Does your child?
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Never
Sometimes
Often
Always
Jump a lot?
Seem fearful of space?
Get car sick?
Like fast movements?
Have trouble learning to climb stairs?
Walk on toes, now or in past?
Appear clumsy or fall often?
Have poor motor coordination with small things?
Hesitate to try new tasks?
Have definite fears?
Have temper tantrums?
Display affection for others?
Have difficulty falling asleep?
Impulsivity or hyperactivity?
Usually distractible?
Have an awkward pencil grasp?
Appear to have a normal sense of taste?
Appear to have a normal sense of smell?
Tend to explore orally or with smell?
Have trouble learning urinary control?
Have trouble with bowel control?
Respond negatively to loud noises?
Miss hearing some sounds?
Unable to follow 2-3 step directions given at once?
Have difficulty paying attention when there is other noise present?
Like to sing or dance to music?
Have difficulty copying rhythms?
Have difficulty remembering what was said?
Avoid hard or crunchy food textures?
Keep an open mouth posture at rest?
Suck his/her thumb or fingers?
Frequently mouth toys/objects?
Avoid putting hands in messy situations?
Dislike being touched unexpectedly?
How sensitivity to clothes/tags?
Prefer to touch rather then be touched?
Pinch, bite or otherwise hurt themselves?
Enjoys being in the dark?
Reverses numbers or letters?
Has difficulty with eye contact?
Rocks in bed, past or present?
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Speech and Language Development
What were your child’s first words?
*
How many words does your child currently use?
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0-5
10-20
20-50
50-100
100+
How does your child make his/her needs and wants known?
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Crying/Yelling
Pointing
Gestures
Gestures/Sounds
Gestures/Words
Single Words
Phrases
Sentences
Please list any two-word phrases that your child uses purposefully:
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Is your child difficult to understand at times?
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Please list any other languages spoken in the home and the percentages which they are spoken.
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Fluency
Does your child stutter?
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Yes
No
How long have you observed stuttering?
Voice
Does your child’s voice exhibit any of the following qualities?
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Hoarse
Harsh
Nasal
Very Soft
Very Loud
Feeding
Have there been any feeding problems?
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Are there any problems with sucking, chewing, choking or swallowing?
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Are there any texture preferences for feeding (ie, hard, crunchy, mushy)?
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Have there been any problems with liquids?
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What are some foods that are typical in the child’s diet?
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Social Development and Play Skills
Describe your child’s personality:
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Does your child enjoy playing with other children?
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What does your child do when angry or frustrated?
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What makes your child smile and/or laugh?
*
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Sensory History
Has your child had an eye examination?
*
Yes
No
Date of last testing?
-
Month
-
Day
Year
Date
What were the results of the last exam?
Does your child wear glasses?
Yes
No
Are there sounds that your child particularly likes or dislikes?
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Are there textures that your child likes or dislikes?
*
What foods does your child particularly like?
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Does your child like or dislike any particular odors?
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