Pediatric Skill Builders

Occupational and Physical Therapy Services in Orlando, Florida

Child holding paint brushes

Child Therapy Case History Form

Pediatric Skill Builders requests this information for the purpose of completing your evaluation.

General Information

Child's Name
Date of Birth
Age
Today's Date
Referred By
Physician
Name of Person Completing Form

Which services are you interested in?

What are your main concerns?



Therapy Precautions (Please List)

Does your child have food alergies?
Does your child have any movement restrictions?
Are there any other precautions that we should know about?
Does your child have any other allergies?


Family History

Father's Name
Age
Occupation
Mother's Name
Age
Occupation
Is he/she adopted?
If so, at what age was he adopted?
Who lives in this house with this child?

Have there been any of the following in your immediate or extended family?





Medical History

Were there complications during pregnancy?
Was the pregnancy full-term?
Were any drugs or medications taken during the pregnancy?
Was labor and delivery normal?
Please list birth weight and length:
Describe any major accidents or hospitalizations:

Pregnancy and Birth History

Has your child had any of the following? If yes, please explain:

Meningitis?
Chicken pox?
Seizures?
Head injury or head trauma?
Allergies?
Frequent ear infections?
P.E. ear tubes inserted?
Excessive vomiting or reflux?
Cleft palate?
Vision problems?
Other problems?
Does your child have a medical diagnosis (i.e. Autism, ADD, Down Syndrome)?
Is your child taking any medications?
Has your child had a vision exam?
Has your child had a hearing exam?


Growth and Development

At what age did your child:

Roll over from stomach to back?
Roll from back to stomach?
Sit independently?
Crawl?
Walk, holding onto furniture?
Walk independently?
Speak first word?
Speak in 2-word sentences?
Drink from a cup?
Use a spoon?
Dress independently?
Toilet trained?

Which of the following is your child able to do?


Please describe your child. Check all that apply:

Other? Please explain:

Has your child established a hand preference?


Please describe how much help, if any, your child requires with self-care skills: (dressing, bathing, feeding, etc.)
Please describe your child’s balance skills and motor coordination:
Please describe any sensory issues / concerns:
(sensitivity to touch, smell, sound, gets dizzy and/or tires easily, avoids/craves messy activities)


Educational Background

Does your child attend school?

If so, where?

Has your child ever repeated a grade?


If so, which grade?

Does your child receive therapy services in school?


If so, what services?
How often?
How long?
Individual or group?
Other: (please explain)

Has your child received therapy anywhere else?


If so, what therapies?
Where?
By whom?
What therapy goals have your child focused on?
Are there any religious or cultural issues that we should be aware of regarding your child’s evaluation?
What are your child’s favorite play activities and/or favorite interests?
What goals are you seeking for your child?
Please add any additional information that you feel will help us understand your child and your concerns:


Person completing form:
Relationship to child:
Today's date:

Instructions

Please fill out each field if possible and click "Submit". If you have any difficulty, please contact us at (407) 389-4357.