PEDIATRIC - CASE HISTORY FORM
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- Dortha Griffin
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1 Thank you, for choosing Access Rehab Centers. We kindly request that you fill out all the necessary information for our therapists to complete a comprehensive evaluation of your child. Please mail this packet back prior to the evaluation, if possible, so it can be reviewed. PEDIATRIC - CASE HISTORY FORM Child s Name: Date of Birth: Address: Phone: City, State, Zip: Who does the child live with? Mother s Name: _ Age: Mother s Occupation: Work Phone: Father s Name: Age: Father s Occupation: Work Phone: Referred by: Phone: Address: Pediatrician: Phone: Address: Other Doctors: Phone: Address: Brothers & Sisters (including names and ages): What languages does the child speak? What languages are spoken in the home? What is the child s primary language? What is the primary language spoken in the home? With whom does the child spend most of his/her time? Page 1 of 7 Peds Case History - - Rev: 7/2013
2 How does your child usually communicate? (Gestures, single words, short phrases, sentences.) Why are you bringing your child in for an evaluation? What are the problems that have been noticed? (Does not talk, can not sit still, has a diagnosed condition, etc.) When was the problem first noticed? By whom? What do you think caused the problem? Has the problem changed since it was first noticed? Is the child aware of the problem? If yes, how does he/she feel about it? Is your child or was the child involved in a birth-to-three program? Have any other specialists seen the child? (Physicians, psychologists, special ed teachers?) Who and when? What were their conclusions/suggestions? Have any other therapists seen the child? (Speech, occupational or physical therapy) and was it for the same problem? Does anyone in your family have similar problems to those of the child? Page 2 of 7 Peds Case History - - Rev: 7/2013
3 PRENATAL AND BIRTH HISTORY Mother s general health during pregnancy (illness, accidents, medications, etc.) Length of pregnancy: Length of Labor: General Condition: Birth Weight: Circle type of delivery: Head first Feet first Breech Caesarian Were there any unusual conditions that may have affected the pregnancy or birth? MEDICAL HISTORY Provide the approximate ages at which the child suffered the following illnesses and conditions: Allergies Asthma Chicken Pox Colds Convulsions Croup Dizziness Draining Ear Ear Infections Encephalitis German Measles Headaches High Fever Influenza Mastoidtis Measles Meningitis Mumps Pneumonia Seizures Sinusitis Tinnitus Tonsilitis Other Has the child had any surgeries? If yes, what type and when? (ex. Tube placement, tonsillectomy) Describe any major accidents or hospitalizations. Is the child taking any medications? Please list name and reason for medication. Have there been any reactions to medications? If yes, please describe. Has the child had a hearing test? Results? Page 3 of 7 Peds Case History - - Rev: 7/2013
4 DEVELOPMENTAL HISTORY Provide the approximate age at which the child began to do the following activities: Crawl Use Single Words (no, mom, dog) Sit Combine Words (me go, daddy shoe) Stand Name Simple Objects (dog, car) Walk Use Simple Questions (where s doggie?) Feed Self Engage in Conversation Dress Self Use Toilet Does the child have any difficulty walking, running, or participating in other activities which require small or large muscle coordination? Do you feel your child is excessively clumsy? Are there or have there ever been any feeding problems (problems with sucking, swallowing, drooling, chewing, etc). If yes, please describe. Describe the child s response to sound (afraid of loud noises, responds to all sounds, inconsistently responds to normal sounds, etc.) Does your child require assistance with daily activities dressing, showering, use bathroom, feeding, etc? If yes, please describe level of assistance needed. Page 4 of 7 Peds Case History - - Rev: 7/2013
5 EDUCATIONAL HISTORY School: Grade: Teacher: Has the child been diagnosed with any type of learning disability? How is the child doing academically (or pre-academically)? Does the child receive special services? If yes, please describe: How does the child interact with others (shy, aggressive, uncooperative, etc)? Does the child s teacher have any concerns? Please list any special education services the child receives. Is your child enrolled in public, private, parochial, or alternative school? Page 5 of 7 Peds Case History - - Rev: 7/2013
6 SENSORY INFORMATION Does your child tend to fall down or bang into things a lot? Does your child have a bad reaction to: Loud noises Yes No Dirt, paint, etc on hands Yes No Certain food textures Yes No Having teeth brushed Yes No Having hair brushed Yes No Tags in clothing Yes No Wearing socks or tight clothing Yes No Car sickness Yes No Being touched Yes No Does the child have a normal response to pain? Is your child what you might call hyperactive (always moving, can t sit still)? Does your child seem overly lazy (never wants to do any activity)? Page 6 of 7 Peds Case History - - Rev: 7/2013
7 ADDITIONAL INFORMATION Please provide any additional information that might be helpful in the evaluation or remediation of the child s problem. Person completing form: Relationship to child: Signature: Date: Please return this packet of information by mail prior to the evaluation, if possible, so the therapists can review the child s history and prepare the necessary evaluation. If it is not possible to return these prior to the evaluation, please bring them the day of the evaluation. On the day of the evaluation, you will need: Insurance information Prescription from the physician ordering the therapy evaluation (if MD did not fax it directly to Access Rehab Centers.) Copy of Individualized Family Service Plan from school (IFSP) if child has one. Copy of any evaluations done by specialists (psychologist, neurologist, etc.) The child can not be seen without a valid and current prescription. When Access Rehab Centers receives authorization from the child s insurance company, sessions can begin. Most insurance companies will give authorization within two weeks of the initial evaluation. Thank you for taking the time to fill out this important information. Please mail it back us as soon as possible to the address at the top of the first page. If this is not possible to mail this form, please be sure to bring it with you to the evaluation. Page 7 of 7 Peds Case History - - Rev: 7/2013
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