auburntherapy

CHILD CASE HISTORY FORM
Welcome to Auburn TLC! In order to help us achieve our mission of providing the highest quality treatment for your child, please fill out this form as accurately as possible. We look forward to working with you and your child.
Today's Date

MonthDayYear
Date
Client date of birth

MonthDayYear
Date
Child's Name
Nickname
Person completing this form & relationship to the client
Is English the primary language spoken in the home?
Other language(s) spoken in the home
Area(s) of Concern
What are your concerns about your child's development?

0/50
When did you notice these concerns?
Has your child previously received services (OT, PT, speech therapy, ABA therapy?
If yes, when and where?

0/80
Prenatal and Birth History
Mom's age at birth
Dad's age at birth
Length of Pregnancy
Child's weight at birth
Type of Delivery
Any illness or accidents experienced during pregnancy?
If yes, please provide details, including any medications used.

0/50
Was your child's delivery normal?
If no, please provide details

0/80
Did your child experience any health problems during or after birth? (health, swallowing, sucking, feeding, sleeping)
If yes, please provide details

0/80
Medical History
Has your child ever had surgery?
When?
If yes, please explain
Has your child ever been hospitalized?
If yes, indicate when and explain
Has your child ever experienced any of the following? Check all that apply and please indicate age of occurrence:
Adenoidectomy
Age
Allergies
Age
Asthma
Age
Blood Disease
Age
Chickenpox
Age
Chronic Colds
Age
Croup/Whooping Cough
Age
Dental Problems
Age
Ear Infections
Age
Ear Tubes Inserted for Ear Infections
Age
Encephalitis/Meningitis
Age
Headaches
Age
Head Injury
Age
Heart Problems
Age
High Fevers
Age
Influenza
Age
Measles/Mumps
Age
Neuromuscular Disorders
Age
Rheumatic Fever
Age
Pneumonia
Age
Other
Please list any diagnoses your child has
Is your child currently taking any medications? If yes, please indicate below
Medication
How often does the child take the medications listed above?
What is the purpose for each of the medications listed.
Please list any allergies your child has, especially food allergies
Speech and Language Development
At what age did your child speak his or her first word?
Did it ever seem like your child started losing words?
If yes, when?
How does your child primarily communicate?
When your child uses words what percentage of his/her speech is understood?
Does your child understand the following?
Gross Motor Development

Please indicate the ages when these skills were observed
Holding head up while lying on stomach
Still an area of concern?
Rolling over
Still an area of concern?
Sitting unsupported
Still an area of concern?
Crawling
Still an area of concern?
Pulling to stand
Still an area of concern?
Cruise along furniture
Still an area of concern?
Sitting unassisted
Still an area of concern?
Walking unassisted
Still an area of concern?
Fine Motor Skills Development

Please indicate the ages when these skills were observed
Reaches and grasps objects
Still an area of concern?
Transfers objects from one hand to the other
Still an area of concern?
Grasping objects with index finger and thumb
Still an area of concern?
Feeds self with fingers and/or utensils
Still an area of concern?
Stacks books
Still an area of concern?
Copies drawn lines and cuts with scissors
Still an area of concern?
Sitting unassisted
Still an area of concern?
Counts to 5 using fingers
Still an area of concern?
Uses knife for cutting
Still an area of concern?
Correctly holds a pencil/crayon
Still an area of concern?
Writes own name
Still an area of concern?
Completes simples puzzles
Still an area of concern?
Education History
Does the child attend day care or school?
Name of Day Care or School
Grade (if attending school)
Teacher's Name
Does your child have an Individualized Education Plan (IEP)? If yes, please provide a copy of the IEP
Does the child have any siblings?
Child 1 Name
Age
Sex
History of speech, language, hearing or medical problems?
Child 2 Name
Age
Sex
History of speech, language, hearing or medical problems?
Child 3 Name
Age
Sex
History of speech, language, hearing or medical problems?
Child 4 Name
Age
Sex
History of speech, language, hearing or medical problems?
Behavior

Please check all that apply to your child
Type a question
Please describe any behaviors listed above
Self-Help Skills
Please check the box next to the skills your child is able to complete independently
Bladder trained during day
Age
Bladder trained at night
Age
Bowel trained during day
Age
Bowel trained at night
Age
Please check the boxes that describe your child
Please provide additional comments pertaining to concerns with social/emotional development
Please provide additional comments pertaining to the completion of these skills
Social/Emotional Development
Should be Empty:

CHILD CASE HISTORY FORM

Area(s) of Concern

Prenatal and Birth History

Medical History

Speech and Language Development

Gross Motor Development

Fine Motor Skills Development

Education History

Behavior

Self-Help Skills

Social/Emotional Development