Pediatric Case History Form

Pediatric Case History Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
School *
Grade *
IEP *

Yes No

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian(s) Name: *

First Name Last Name
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Email *
Child's Pediatrician *
Has Child Had Speech, Physical and/or Occupational Therapy In The Past? *
Other Providers Seen For This Condition: *

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? *

Social Development and Play Skills
Describe your child’s personality: *
Does your child enjoy playing with other children? *
What does your child do when angry or frustrated? *
What makes your child smile and/or laugh? *

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? *
Are there textures that your child likes or dislikes? *
What foods does your child particularly like? *
Does your child like or dislike any particular odors? *
Should be Empty: