Pediatric Case History
Please fill out this form as completely as possible. This history form provides necessary background information so your therapist can prepare the most appropriate evaluation.
PREGNANCY/BIRTH AND MEDICAL HISTORY
FAMILY/SOCIAL HISTORY
DEVELOPMENTAL HISTORY
Please indicate at what age your child achieved the following skills and any comments:
Activities of Daily Living:
Motor Skills:
Speech and Language Skills
Feeding and Swallowing
Sensory Issues (reaction or response if your child does not tolerate)
Thank you for taking the time to complete this form. This information will be extremely helpful to your therapist in creating a treatment program specific to your child's needs. created 2/9/2021