Case History – Age 4 And OlderHow did you hear about us?* Physician referral Word of mouth Facebook/instagram Google search Magazine advertisement OtherName Of PhysicianName of PublicationOther DetailsClinic Location Child has appointment scheduled at* Pooler Richmond HillChild’s Name*Birth Date* MM DD YYYYPreferred Name*Sex*MaleFemaleParent/Caregiver*Email* Phone Number*Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child lives with*Both ParentsMotherFatherGrandparentsAre there any guardianship/custody issues our office should be aware of?*YesNoPlease briefly describe*Primary Care Physician*Medical Diagnosis*Primary Concerns/Reason for Referral*Has your child previously received therapy before? Select all that apply. ST OT PTWhere were services received and for how long?*Why did your child discontinue receiving services?*Emergency Contact(s)*Phone*Hospital PreferenceIn the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.Signature of Parent/Guardian*Date* MM DD YYYYFAMILYNames and ages of siblingsNameAge Names and nicknames of family members close to your child: (ie: ‘nona’/grandmother)NameNickname Names of pets PRE-NATAL & BIRTH HISTORYBirth Type*PrematureFull termBirth uneventfulBirth eventfulHow many weeks?*Please describe*Please describe any pre-natal issuesWas the child in the Newborn Intensive Care Unit?*YesNoFor how long?*DEVELOPMENTAL MILESTONESSat at ageWalked at ageFirst words at ageCombined words at agePlease list any developmental milestones NOT met within appropriate timeframesMEDICAL HISTORYPlease elaborate if any of the following are checked Hospitalizations Surgeries Medication Seizures Breathing Problems/Asthma Allergies Ear infections Frequent upper respiratory infections GERD Eats well Picky eater Nutrition a concern Sleeps well? OtherPlease list all surgeries and dates*SurgeryDate Please list all medications*Name of MedicationWhat addressing?DosageSide Effects Please list allergies*Ear infections-How frequently?*GERD- age diagnosed*GERD- How treated?*GERD- Have symptoms resolved?*YesNoCurrent Weight?*Current Height?*Please describe your child’s health in generalHEARINGHas your child had any ear infections?*YesNoPlease list dates and treatment*DateWhere tested?Results Has your child had PE tubes placed?*YesNoHas your child been diagnosed with hearing loss?*YesNoWhat type and severity?*Does your child regularly wear aided hearing device?*YesNoVISIONHas your child had his or her vision checked?*YesNoWhat were results?*Does your child wear corrective lenses?*YesNoDoes your child have a history of Estropia, Strabismus, Patching or Eye drop prescriptions?*YesNoPlease specify*DENTAL/ORAL HEALTHDoes your child regularly see a dentist?*YesNoHow often?*Does your child allow you to brush his/her teeth?*YesNoHas your child used a pacifier?*YesNoAt what age did the child stop?*Does your child put toys or objects in his or her mouth?*YesNoBEHAVIORAL CONCERNSPlease check all that apply Cries often Dislikes hair brushing Rocks self Frequent temper tantrums Dislikes tooth brushing Is sensitive to light Poor attention span Sensitive to Sound Anxious Has trouble making friends Avoids touch from others Trouble with changes in routine Always “on the go” Clumsy Weak MusclesCommentsEDUCATIONAL INFORMATIONSchool/Educational Program Currently AttendingGrade LevelDoes your child have an IEP?YesNoSpecial Services ReceivedDoes your child’s teacher express concerns with his or her development or educational performance?YesNoIn what areas: (please check all that apply) Motor Skills Social Skills Overly Active Difficulty Calming Down Is sensitive to bright lights Poor attention span Sensitive to Sound Anxious Has trouble making friends Trouble with changes in routine Handwriting Reading Comprehension Sensory Processing/Sensory Regulation Trouble Following DirectionsIs there anything else that you feel would be beneficial for us to know about your child? ShareTweetSharePin0 Shares