Child Case History Form

Child Case History

Section 1
General Information

Today's Date

Child's name*

Date of Birth*

Gender*

Age*

Address*

State*

Home Phone*

City*

Zip Code*

Allergies



Emergency Contact Information

Name*

Phone Number*

Relationship to Client


Does the child live with both parents?

If divorced, who has custody?

Who does child spend most of his/her time with?


Mother's Name

Occupation

Home Phone

Cell Phone

Email

Father's Name

Occupation

Home Phone

Cell Phone

Email

Siblings



Age



Other people in the home



Relation





Section 2
Physician Information

Child's Physician

Address

Phone Number

City



Section 3
Child's Behavior

What language(s) does the child speak?

How does the child usually communicate?

GesturesSign LanguageSingle WordsShort PhrasesSentences

How does your child tell you what he/she wants?

Does he/she follow directions?

Do you feel like he/she understands most of what you say?

When did you first become concerned?

Since you first became concerned, what changes have you observed in your child’s speech, language, or hearing?

Describe other speech, language, or hearing problems in the family.



Section 4

Is the child adopted?

If yes, at what age did the child join the family?

Normal pregnancy and delivery?

Weight at birth

Vaginal delivery?

Cesarean delivery?

Full-term pregnancy?

Alcohol, drugs, smoking, or any medications during this pregnancy?

If so, please list.

Did your child have jaundice?

Was oxygen or respiratory assistance required after birth?

Was your child breast fed?

Any difficulties with feeding?

Did your child have normal feeding, weight gain, sleeping cycles, and temperament?



Section 5
Prenatal​ ​and​ ​Birth​ ​History

Describe mother’s general health during pregnancy (illness, accidents, prescription and non-prescription medications, etc.).

Length of pregnancy:



Section 6
Medical History

Child’s general health is:

Is your child on any medications?

Describe any major illnesses, accidents, surgeries, or hospitalizations the child has had.

Has your child had ear infections?

How many ear infections?

Does your child have tubes?



Section 7
Developmental​ ​History
Please complete this section to the best of your ability.
Write the approximate age when the child began to do the following.

Crawl

Feed Self

Combine words

Sit

Dress self

Name simple objects

Stand

Use toilet

Use simple questions

Walk

Use single words

Engage in a conversation

Does your child have any motor difficulty, such as walking or running?

Describe any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing, etc.) your child has had.

Does your child:

Respond to sounds?

Respond to sounds inconsistently?

Do you suspect any problems with hearing?


Section 8
General​ ​Behavior

Do you have any concerns with eating or sleeping?

How does the child interact with other family members?

How does the child interact with other children?

Do you have any other relevant concerns?


Section 9
Educational​ ​History​

School or Preschool

Grade

Teacher(s)

Describe any special services your child receives.

If enrolled for special education services, list main goals of the Individualized Educational Plan (IEP) or Individual Family Service Plan (IFSP).

Does your child receive any other private services?

ABA Agency name:

Phone:

Occupational Therapy:

Phone:

Physical Therapy:

Phone:

Other:

Phone:


How did you hear about The TALK Team?



Section 10

The​ ​information​ ​provided​ ​in​ ​this​ ​document​ ​regarding​ ​my​ ​child​ ​is​ ​accurate​ ​and​ ​consistent​ ​to​ ​the best​ ​of​ ​my​ ​knowledge.

Electronic Signature

Relationship to the patient

Date