TW-THERAPY CASE HISTORY FORM

CASE HISTORY FORM

We are a paperless practice that uses HIPAA-compliant electronic health records. All information provided will be confidential.

Please do not print these forms. Please fill them out online at least 24 hours before your appointment.

This form will take approximately 15 minutes to complete

For questions, please call (770) 995-2379.

Thank you!

PATIENT INFORMATION
Patient's Name*
Date of Birth*

MonthDayYear
Date
Parent's Name*
Phone Number*
Why are you seeking therapy services?:*
Child's Medical Diagnosis, if any:
Has the child been evaluated or received previous therapy?*

YESNO
If YES, please check which one/s:*

Occupational TherapyPhysical TherapySpeech TherapyBehavioral Therapy/ABACounsellingVision TherapyOther
Name of Previous Therapy Clinic/Facility:
Last Time Child was Seen for Therapy:

MonthDayYear
Date

DEVELOPMENTAL MILESTONES
Were developmental milestones achieved within normal limits?*

YESNO
If not, please explain delays:
When did the child:
Sit up*
Crawl*
Stand*
Walk*
Self feed*
Self Dress*
Toilet trained*
Babble*
Use Single words*
Combine 2 or more words*
Does the child have SPEECH AND LANGUAGE DELAYS/DIFFICULTY SPEAKING?*

YESNO
Does the child have FEEDING PROBLEMS?*

YESNO
Does the child have VISION PROBLEMS/DIFFICULTY SEEING?*

YESNO