Elgin Pediatric Case History Form
Please fill out relevant information only
Date:
Person filling out this questionnaire______Relationship to child______
Identifying Information
Name of child______
Nickname______
Date of Birth______Child’s age______
School attending ______Grade ______
Language(s) spoken in the home ______
Other children in the family:
NameSexAgeSchool-Grade
______
______
______
Concerns
Describe, in your own words, your concerns regarding your child’s development. ______
Does your child have a formal diagnosis? Yes _____ No ______If yes, what is it?
______
When was it made?______By whom?______
Birth/Medical History
Did the mother have medical problems during the pregnancy? Yes___ No____ If yes, please describe______
______
Did the mother take any prescription and/or nonprescription medication during this pregnancy?_____ If yes, what kinds?______
Was the child full-term?_____ If no, what was the gestational age?______
Was the delivery normal?______If no, explain______
______
Caesarian?_____ If yes, reason______
How long were the mother and child in the hospital?______
Child’s weight at birth?______
Any birth injuries?______
What special medication attention or treatment did the child receive at birth, if any?____
______
Did your child pass his/her hearing screening at birth?______
Where there any feeding difficulties during infancy?______If yes, please describe____
______
______
Does your child have any food allergies?_____ If yes, please list______
______
Development History
Did your child make babbling/cooing sounds in first 6 months of life? Yes____ No____
At what age did your child say his or her first words?______
What were the child’s first words?______
At what age did he/she begin using 2 and 3 word sentences?______
Did speech learning ever seem to stop for a period of time? Yes______No______
If yes, explain______
Does your child consistently answer to his/her name? Yes____ No_____
Does your child make appropriate eye contact? Yes____ No_____
Does your child follow simple commands? Yes____ No____
Does he/she like taking a bath?______swinging?______parties?______rough housing?______
Child prefers to primarily play: alone_____ with other children______with older children______with younger children______with adults?______
Is your child overly sensitive to loud sounds?______bright lights?______tags on clothing?______
Give ages at which the following first occurred:
Sat up ______crawled______stood______walked______ran______bladder trained______bowel trained______night trained______
What does your child enjoy?______
______
Family History
Are there any members of your immediate family that have been diagnosed with any of the following: (please indicate which family member)
______learning disability
______dyslexia
______speech and language delay/disorder
______sensory processing disorder
______auditory processing disorder
______ADD/ADHD
______autistic spectrum disorder/PDD
______other, please explain ______
Does your child have any behavioral or attentional issues at school/daycare?______
______
______
Describe any speech, language, hearing, OT, PT, special education services, tutoring that the child is receiving/has received. If your child currently has an IEP, or has previous evaluation documentation, please provide a copy.
______
______
______
______
Any other concerns or relevant information: ______