Pediatric Case History Form

Address *

Educational History
Does your child attend daycare/preschool? Where: *
If your child attends school (grades K-12) please describe his/her overall performance: *
Does your child get along with others in school/daycare/preschool: *
Provide the age your child was able to complete the activity.
Held Up Head Alone *
Sat Alone *
Stood Alone *
Fed Self With Spoon *
Independently Dressed *
Said First Word *
Rolled Over Alone *
Crawled *
Walked Unaided *
Potty Trained *
Drink Only From Cup *
Combined Words *
Are there any specific questions you have about your child that you would like us to try to address during the assessment? *
What are your goals for therapy? *

	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?