Medical and Social History Form - Initial Evaluation
If an item is not applicable to you, please enter N/A in the text box.
Child's Name
Date of Birth
Filled out by (Name/relation to child)
Daycare
Drop off and pick up times
If your child is not in daycare, what is the structure of your child's care during the week?
Preferred Days and Times (AM/PM) for services if AT CLINIC. *These times are not guaranteed.
Developmental Information
Length of Pregnancy
Birth Weight
Complications with pregnancy and/or delivery
Method of delivery
Vaginal Delivery
Cesarean Section
Child's health at birth:
Passed newborn hearing screening?
Yes
No
History of Ear Infections including dates:
Month/Year PE Tubes placed:
The child met the following milestones at what age:
Roll over:
Sit independently:
Crawl:
Walk:
Potty trained:
First word(s) in context:
First word(s) at what age:
Medical Diagnoses:
Do you have concerns of a medical diagnosis? (Autism, ADHD, etc) If so, please explain.
Have you discussed developmental concerns with your child's PCP?
Medical Information:
Illnesses and/or Hospitializations
Allergies or Special Diet (please include severity and reaction):
Medications and Dosages:
Please list any medical specialists your child sees:
Has your child received therapy before (yes or no) and with what company?
Date of last Speech Therapy evaluation:
Date of last Occupational Therapy evaluation:
Date of last Physical Therapy evaluation:
Has anyone else in the family ever received or does anyone currently receive therapies and/or does anyone have any medical dianoses that have affected development?
Family Information:
Please tell us about any family traditions, cultural or religious beliefs of which you would like us to be aware:
Please list all languages spoken in the home and who speaks them.
If there are multiple languages spoken in your home, please estimate the amount of time your child is exposed to each language (estimate in percentages)
Who all lives in the home? Please list the ages of any siblings.
Does this child split his or her time between homes? Please specify.
Is this child currently in Foster Care?
Yes
No
If yes, pleae provide available circumstantial information regarding placement, length of placement, and family reunification or adoption plans:
Personal Factors:
What is your child's personality like? (are they shy, talkative, etc?)
What strengths does your child have?
What weaknesses does your child have?
What are your child's daily routines or what is expected of them for the following at home:
Social Interactions:
Play (by themselves or with others?)
Self-care (dressing, bathing, etc):
Is your child able to meet the above expectations within the family structure? Please explain.
Does your child present with any aversive (negative or avoidant) behaviors? If so, to what does the child negatively respond, and what do you typically do to try to redirect said behaviors?
Child's favorite toys and activities:
Child's use of electronics and how often:
Child's opportunities for interactions with other children/How does the child interact with others?
How many hours of sleep does your child get per night?
Sleep quality: please check which of the following apply to your child
My child snores
My child is a restless sleeper
My child wakes up multiple times a night
My child co-sleeps with me
My child shares a bed with siblings
My child shares a room with siblings
Other
Use this space to list “other” information about sleep quality
Nutrition intake: does your child eat a variety of Whole Foods? Is the diet restricted due to sensory concerns or family food choices?
Please estimate your child’s daily water intake in cups.
How often does your child have access to water/hydration at school/daycare? (Ex. All day, only at lunch, only at lunch and snacks)
Does your child still use a pacifier?
Yes
No
If your child still uses a pacifier, how often is it used? (Ex. Throughout the day, only to soothe, only when sleeping)
The following questions are specific to school-age children (ages 5 years and older):
Does your child currently receive services at school?
Yes
No
If yes, what type (specific therapy, resource classes, counseling, etc.) and for how many minutes per week?
Is your child receiving services under a 504 plan or an IEP?
Yes
No
What accomodations do they receive in the classroom as written in their 504 or IEP plan?
How is your child's performance at school? Does your child have any difficulty in school? Please explain:
Concerns Related to Specific Therapy Services:
I have concerns for my child in the following areas (please select all that apply):
Speech and Language:
Use of age-appropriate language concepts
Does not seem to have enough words
Refuses to use words/language
Uses gestures more than words to communicate wants/needs
Misses or omits sounds from words at the beginning, middle, or end of words
My child is 3 or older and I am the only person who can understand what my child is saying
My child is over age 4 and seems to stutter or get stuck on words
I have no speech and language concerns at this time
Please provide any additional information regarding speech, language, articulation, or fluency concerns:
Occupational Therapy:
Fine Motor Skills (buttons, zippers, manipulating toys)
Pre-writing skills (drawing lines/shapes)
Tracing/coloring
Visual perception (Puzzles, matching pictures)
Grasping: weak grasp
Grasping: too much pressure
Is 3 years old and does not have a preferred hand for coloring/drawing, throwing, eating, etc.
Self-care (using utensils, dressing self, toileting hygiene, hand washing, putting on/tying shoes)
I have no Occupational Therapy concerns at this time
Sensory Processing (follow directions, play with peers, tolerate change/transitions, emotional regulation, behavior, attention)
Please provide any further infromation regarding fine motor, self-care, and/or sensory processing concerns:
Physical Therapy:
Balance
Strength
Climbing/descending stairs
Crawling
Walking/Running
Jumping
Throwing/Catching/Kicking a ball
Overall Gross motor movement coordination
Clumsy/accident prone
Safety on playground equipment
Torticollis
Alignment of the spine, hips, knees, or ankles
Muscle Tone (floppy or too rigid)
I have no Physical Therapy concerns at this time
Please provide any further information regarding gross motor, balance, and coordination skills:
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