Milemarkers Therapy Inc.
1515 Lake Havasu Ave. N #100
Lake Havasu City, AZ 86404
Phone # (928) 854-KIDZ (5439)
Fax# (928) 854-5440
Case History Form
Name of child: ______Sex: ______Age: ______DOB: ______
Phone number: (home)______(work)______(cell)______
Parent/guardian name: ______
Referral source: ______
Primary Language of Child: ______Primary Language in home: ______
Address: ______
Sibling information (names and ages): ______
______
Others in Home: ______
______
Has your child ever received speech, occupational or physical therapy services before? If so, when and where: ______
______
______
REASON FOR REFERRAL
What are your concerns regarding your child and when did you first become concerned?
______
Does your child have any other related difficulties or diagnoses? (i.e. vision, hearing, learning disabilities, motor deficits, emotional problems, behavioral problems, etc.)
______
MEDICAL HISTORY
Please describe any accidents or serious injuries that your child has experienced.
______
Has your child had any surgeries or hospitalizations? (Please give date and type of procedure) ______
Has your child ever worn braces? (i.e. leg, arm) ______
Does your child use eye glasses or hearing aids?______
Is your child currently taking any medications? (Please list type and reason)
______
Please check all that apply:
Pregnancy:Bleeding? ______When?______
Mother needed medication? ______
Vomiting? ______
Excessive weight gain? ______
Limited weight gain? ______
Toxemia (metabolic disturbance) ______
Maternal Seizure disorder ______
Maternal alcohol abuse ______
Maternal drug use ______
Previous miscarriage(s) ______
Previous stillbirth(s) ______
Other (please specify)______
______/ Delivery:
1.Difficult birth _____
2.Labor less than two hours _____
3.Labor lasting more than 12 hours____
4. Cesarean section _____
5. Breech birth _____
6. Cord around neck _____
7. Baby needed oxygen _____
8. Jaundice (yellow) _____
9. Baby had respiratory distress _____
10. RH incompatibility _____
11. Premature _____
If so, gestational age? _____
12. APGAR score _____
Infancy:
1. Weight at birth ______
2. Difficulty sucking ______
3. Difficulty swallowing ______
4. Trouble sleeping ______
5. Cried excessively ______
6. Diarrhea ______
7. Other (please specify) ______/ Significant Medical History:
1. Allergies _____
2. Asthma _____
3. Cerebral Palsy _____
4. Cleft lip/palate _____
5. Ear infections _____
6. Encephalitis _____
7. Failure to thrive _____
8. Heart disease _____
9. High fevers _____
10. Meningitis _____
11. Eye problems _____
12. Seizure disorder _____
13. Other (please specify) _____
DEVELOPMENTAL HISTORY
Early motor development
_____Age child sat alone
_____Age child crawled
_____Age child walked alone
_____Age child was fully toilet trained
Early speech/language development
_____Age child spoke first true word
_____Age child put two words together
_____Age child began using simple sentences
As a baby, did your child enjoy sound play? ______
Do you question your child’s gross motor development? ______
Do you question your child’s fine motor development? ______
Has you child’s hearing ever been formally tested? If yes, what were the results? If no, have you ever questioned your child’s hearing? ______
______
SOCIAL LEARNING INFORMATION
Does your child attend school? ______Where? ______
How do you think your child’s ability to play and learn compares to children of his/her age? ______
Please describe your child’s strengths and weaknesses in learning and playing.
Strengths______
Weaknesses______
How does your child get along with other children? ______
______
Do you notice any behavior or discipline problems in your child? ______
______
CURRENT SPEECH AND LANGUAGE STATUS
Please describe the kind of language your child currently understands (i.e. following directions, verbal explanations, follows or comprehends a story, understands discussion of past or future events). ______
______
Describe the language your child typically uses (i.e. gestures, approximations, single words, word combinations, phrases, simple sentences, short story). ______
______
Does you child have problems with specific sounds? (please specify) ______
______
Do you have a difficult time understanding your child? ______yes ______no
If yes, what percentage of information do you understand? ______
Do others have a difficult time understanding your child? Please explain: ______
______
Is communication a source of frustration for you or your child? If so, what do you or your child do when frustrated? ______
______
CURRENT FINE AND GROSS MOTOR STATUS
Please describe how your child eats (i.e. utensils used, cup usage). ______
______
How does your child get around? (i.e. crawl, scoot, walk, etc.). Please also describe their coordination: ______
______
What fine motor activities motivate your child and does your child participate regularly? Are there any that frustrate your child? Please explain. ______
______
Please describe what level of assistance your child needs for dressing and undressing? (Keep in mind buttons, zippers, snaps, etc.) ______
______
CURRENT SENSORY STATUS
Please describe you child’s eating habits (likes, dislikes, textures, temperatures): ______
______
Please describe bath time with your child: ______
______
How does your child react to movement? (i.e. swinging, spinning, jumping, twirling, etc.)
______
Please explain your child’s sleep routine: ______
______
Does your child have a low or high tolerance for pain? Please describe: ______
______
How does your child handle transitions? (different locations, activities, change in routine, etc.) ______
______
What are your child’s favorite toys? ______
OTHER PROFESSIONALS YOU HAVE CONTACT WITH
NamePhone number
______
Anything else you want Milemarkers to know about your child: ______