LLA THERAPY CHILD HISTORY FORM FOR CAMPS

GENERAL INFORMATION

Child’s Name:______Age:______

Name by which your child is called:______Date of Birth:______

Pediatrician: ______Diagnosis:______Referred by:______

Briefly describe your child’s problems:______

Briefly describeyourchild’sstrengths:______

The child lives with:______

Names of siblings/ages:______

MEDICAL HISTORY

The child’s current health is GoodFair Poor

Please list all current medications being taken by your child:

MedicationDosageReasons for medication

______

Please list any allergies (medicine, food, environmental):
______

SPEECH-LANGUAGE

Does your child:

Answer when you talk to him/her? SometimesYesNo

Talk about what he/she is doing? SometimesYesNo

Have trouble pronouncing words? SometimesYesNo

Hesitate, repeat or stutter words? SometimesYesNo

Can your family understand your child’s speech?SometimesYesNo

Can people outside your family understand your child?SometimesYesNo

When you talk to your child, how much does he/she understand? Check all that apply.

A few wordsSimple directions Questions

Many words/phrases Complex directionsAlmost everything I say

How does your child usually let you know what he/she wants? Check all that apply.

Points to objectsUses sign language Makes a few soundsUses gestures

Grunts Uses a few wordsUses 2-3 word phrasesUses sentences

What does your child like to talk about?______

______

OCCUPATIONAL THERAPY SKILLS

Does your child have an established hand dominance?Yes: Left RightNo

Does your child use writing tools successfully?Yes No

Does your child cut with scissors?YesNo

Is your child resistive to different textures like glue, paint, etc?YesNo

How much assistance is needed with grooming tasks?NoneMinimal Totally Dependent

How much assistance is needed with dressing tasks?NoneMinimal Totally Dependent

SOCIAL-EMOTIONAL:

How does your child get along with other children?______

Does your child prefer to play alone or with other children?______

Does your child seem overly sensitive to criticism? YesNo

Does your child seem overly anxious or fearful?YesNo

Does your child tend to be quiet or withdrawn?YesNo

Does your child tend to be easily frustrated?YesNo

Does your child tend to be unusually uncooperative or stubborn?YesNo

Does your child have temper tantrums or outburst of anger?YesNo

ORGANIZATION:

Does your child frequently lose things (i.e. homework, coat)?YesNo

Does your child have difficulty tolerating changes in plans?YesNo

Does your child need extra assistance to get started with a task?YesNo

Does your child become easily distracted while working/playing?YesNo

Does your child have a short attention span?YesNo

EDUCATIONAL HISTORY

Is your child enrolled in school or pre-school? YesNo (if no, skip this section.)

Name of school or pre-school:______

Grade:______

How does your child do in school?______

______

______

Does your child receive any special education services? YesNo

Special Education Services / Frequency (times per week) / Duration (minutes)
Speech-Language Therapy
Occupational Therapy
Physical Therapy
Guidance Services
LD Support Services
DH Support Services
Other:

SOCIAL WORK INFORMATION

Are there any community agencies active with your child? YesNo

Agency name:______

THERAPY HISTORY

Has you child been previously tested for therapy services?YesNo

If yes, where and when?______.

Does your child currently receive therapy services elsewhere? YesNo

If yes, where and when?______If no, skip this section

Therapy received:

Physical TherapyFrequency______

Occupational TherapyFrequency______

Speech TherapyFrequency______

OtherFrequency______

ACTIVITY INFORMATION

Describe interests, play activities and toys that your child likes best: ______

SOCIAL GROUP QUESTIONS:

Childs likes and dislikes:______

Please answer yes or no to the following questions:

Able to greet and say goodbye appropriately YesNo

Makes eye contact Yes No

Keeps appropriate distance from people during conversation (not to far or to close) YesNo

Is polite (please, thank you etc)Yes No

Asks appropriate questions YesNo

Answers questions appropriately YesNo

Initiates conversation or a new topic YesNo

Stays on topic Yes No

Plays well with adults YesNo

Plays well with peers YesNo

Shy YesNo

Interrupts YesNo

Speaks to loud YesNo

Shares easily yesNo

Impatient YesNo

Takes turns during conversation yesNo

Takes turns during games/play Yes No

Follows the rules of games/play YesNo

Difficulty showing emotions or talking about them YesNo

Please remember to include any additional information (IEP, ETR, Progress Reports, etc.)

Name of the person completing this history and relationship to child: ______

Date:______Thank you for taking to time to complete this form.

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