Medical and Social History Form - Annual Evaluation-PlayRx

Medical and Social History Form - Annual Evaluation

Please update the following with recent information from the last year. If an item is not applicable to you, please enter N/A in the text box.

Child's Name

Filled out by (Name/relation to child)

Daycare

Drop off and pick up times

Has your child had any new medical diagnoses in the last year? Please specify:

Is your child seen by any new specialists or doctors? Please specify:

Updated Allergies or Special Diet (please include severity and reaction):

Updated Medications and Dosages:

Recent hearing screening date:

Recent hearing screening results:

Any special testing done outside of PlayRx? Please specify with specialty, date, and location of testing.

Do you have any new concerns of a medical diagnosis? (Autism, ADHD, etc) If so, please explain.

Have you spoken with your child's PCP regarding the above concerns?

What progress have you seen your child make in the last year?

Has anything changed in the home in the last year? (Divorce, addition of a child, etc.)

What concerns do you still have for your child?

Anything else we should know?

I have concerns for my child in the following areas: (please mark those areas that apply to your child)

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:

Please provide any further information regarding gross motor, balance, and coordination skills:

Your name:

Your Signature

Date