CLIENT INFORMATION AND HISTORY FORM 2-2025

CLIENT INFORMATION AND HISTORY FORM

FAMILY INFORMATION

Todays Date

Date

Child's Name

Date of Birth

Date

Age

Parent 1 Name and Relationship

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Age

Occupation

Education

Parent 2 Name and Relationship

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Age

Occupation

Education

Sibling Name 1

Age

School/Grade

Any Developmental Concerns?

Sibling Name 2

Age

School/Grade

Any Developmental Concerns?

Sibling Name 3

Age

School/Grade

Any Developmental Concerns?

Please list those who live with your child.

Please list other people who spend time with your child (examples: babysitters, relatives, friends):

Name

Relationship

CLIENT INFORMATION

Briefly describe your concerns regarding your child:

0/120

Briefly describe your child’s strengths:

0/120

Please list any therapeutic equipment your child has (include braces, etc.)

0/50

Is there a family history of developmental disorders?

Please explain:

0/100

Are there any other languages spoken at home besides English?

BIRTH HISTORY

Check which is applicable. This is our

Were there any problems or hospitalizations during the pregnancy with this child?

0/80

Were any prescription or nonprescription medication used during this pregnancy?

0/80

Rows	Yes	No
Was your child premature?
Were there complications with the delivery?
Was the birth by C-section?

Birth weight:

Born at how many weeks gestation:

Was the mother given any drugs during labor and delivery?

Were there any birth injuries?

Did your child receive medication/treatment at birth?

Please provide further explanation for the above answers:

0/80

MEDICAL HISTORY

The child's current health is

Please list all current medications being taken by your child.

Medication

0/60

Dosage

0/60

Reason for Medication

0/60

Does the child have a specific diagnosis:

If so, please describe:

0/60

Does the child have a history of hospitalizations?

Does or did your child ever have any health problems/surgeries outside of those common to childhood?

Does your child have a history of ear infections/PE Tubes?

Please explain any “yes” answers:

0/100

Has your child's hearing been tested?

Results of hearing tests:

0/60

Please list any allergies (medicines, food, environmental):

0/100

DEVELOPMENTAL HISTORY

Milestones - at approximately what age did your child:

Roll over

Babble or coo

Sit alone

Say first words

Creep or crawl

Speak in sentences/combine words

Cruise or walk with support

Undress self

Walk alone

Dress self

Run

Climb stairs

Feeding

Breast or bottle fed?

0/4

If breast fed, for how long?

0/10

Did your child have feeding or swallowing problems in infancy?

If so, please describe:

0/30

Is your child a picky eater?

Please list foods that your child typically will eat:

0/80

What does your child use to drink? (e.g. bottle, sippy cup, etc.)

0/40

Toileting

Is your child toilet trained?

If so, at what age was your child trained?

Motor/Sensory

Rows	Yes	No
Does your child seem sensitive to certain sounds?
Does your child seem sensitive to certain closing or textures?
Does your child seem to seek out or avoid certain movements?
Does your child seem clumsy?
Does your child have poor handwriting?

Please explain any “yes” answers:

0/80

Social-Emotional Behavior, Communication

How does your child get along with other children?

0/10

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

0/10

Does your child tend to be easily frustrated?

Please explain:

0/40

Please describe how you consequence your child when he or she behaves negatively:

0/30

Please feel free to include comments about your child's behavior

0/30

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

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

What does your child like to talk about?

0/40

EDUCATIONAL HISTORY

Is your child enrolled in a school?

Name of school:

Days and hours of school:

Grade:

Teacher:

How does your child do in school?

0/20

Does your child receive any special education services?

If yes, please list type and frequency:

0/20

SOCIAL WORK INFORMATION

Are there any community agencies active with your child?

Agency name:

Name of case worker:

THERAPY HISTORY

Has your child been previously evaluated for/received therapy services?

If yes, where and when?

0/80

Does your child currently receive therapy services elsewhere?

If yes, where and when?

0/15

Therapy received

Frequency of Physical Therapy

Therapist

Frequency of Occupational Therapy

Therapist

Frequency of Speech Therapy

Therapist

Other Frequency

Therapist

ACTIVITY INFORMATION

Describe play activities that your child likes best:

0/100

In our house, we couldn't live without:

0/100

Please describe what you love most about your child:

0/100

Please list some specific goals that you and your family have for your child:

0/100

Additional Comments/Concerns:

0/150

Thank you for taking the time to complete this form.

Name of person(s) completing this history:

Relationship to child:

Date:

Date