• 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

  • Should be Empty: