Dr. Tara McCormick OTD,OTR/L SIPT Certified KiokoCenter, LLC Pediatric Occupational Therapy 820 Turnpike Street, Suite 104 North Andover, MA 01845 Phone: 978-681-6605 Fax: 978-681-6601 Updated October 2016 General Information: Child s Name: Birth Date: Address: Home Phone: Emergency Contact Person: Emergency contact phone: Parent s Name: Parent s Name: Employer: Employer: Work#: Work #: Cell #: Cell#: Email: Email: Names and ages of siblings: Does child live with both parents? Pediatrician s Name: Pediatrician s Address: Pediatrician s Phone: Name of Early Intervention Program (if applicable): Referred by (name, profession, and address): Reason for referral: If in EI, what qualified your child? How long was he/she in EI? Was he/she discharged prior to the age of 3? Previous evaluations (speech, neuro, etc.)? What were the recommendations? Please provide copies of previous evaluations. What is primary language spoken in home? Are there in any other languages spoken or taught? Does child understand 2 nd language? Speak 2 nd language? Please complete the following questions to the best of your abilities. This information is helpful to the clinician in understanding your child s communication and social development. Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 1 of 9
Birth History: Mother s Pregnancy: Were there complications during pregnancy? Were there complications during labor or delivery? Was your child adopted? Was your child born full term? Was your child born premature? Was your child born small for gestational age (SGA)? Was your child breech (feet first)? Were forceps used? Yes No Explain Was suction required? Were there any birth injuries? Was intensive care hospitalization required? Was your child jaundiced? If known, Apgar rating at 1 and 5 minutes? Additional information regarding birth? Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 2 of 9
Medical History: Medical diagnosis (if any) Date of diagnosis Given by Has your child had a hearing test? Yes No Dates: Results: Has your child had a vision test? Yes No Dates: Results: Does your child have any assistive devices (e.g. glasses, hearing aides, communication devices, wheelchair,? Has your child had any of the following? Childhood diseases Major illnesses Congenital abnormalities Surgery Serious injury or injuries Ear infections Tubes in ears Tonsils or adenoids removed Allergies (food or medications) Allergies (environmental) Seizures Other No Yes Date(s) Explain Current medications Dosage Frequency of dosage Are there any medical precautions the therapist should be aware of when working with your child? Any negative reactions to medications in the past? Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 3 of 9
Developmental History: Developmental Milestones: Approximate Age Reached Comments or any unusual habits Speak first words (no, mom, doggie) Combine words (me go, daddy shoe) Speak in sentences (I go now, Mommy at work) Chew solid foods Drink from a cup Feed him/herself Sit alone Crawl Walk Dress him/herself Use toilet Did/does your child.. babble as an infant? respond to people and faces as an infant? have difficulty walking, running, or participating in activities which require muscle coordination? have any feeding problems (e.g. problems with sucking, swallowing, drooling, chewing, etc.)? snore or have difficulty sleeping? show a lack of interest in communicating? show a lack of fear of dangers? Yes No Please describe Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 4 of 9
Sensory and Motor History: Comment as desired and cross out any questions that do not apply to your child. ORAL MOTOR/FEEDING Does your child Drool without noticing? Suck through a straw? Stuff food? Eat in a sloppy manner? Tend to be slow in eating? Avoid foods or textures? If so, please list. Have preferred foods or textures? If so, please list. Have difficulty chewing or swallowing? Keep mouth open most of the time or breathe through the mouth? Other? 3 2 1 Please describe AUDITORY Does your child Have difficulty hearing in background noise? Get distracted by sounds or noises? Have difficulty localizing sound? Mishear words (e.g. cut for cup)? Request repetition or say huh? frequently? Have a short auditory attention span? Fatigue easily when listening? Other? 3 2 1 Please describe MOTOR/SENSORY Does your child Have any sensory or tactile issues? Have any balance issues? Avoid certain types of movement (e.g. climbing, swinging)? Seek out certain types of movement? Demonstrate appropriate gross motor skills? Demonstrate appropriate fine motor skills? Demonstrate any unusual behaviors (e.g. headbanging, hand-flapping, etc.)? Other? 3 2 1 Please describe Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 5 of 9
Communication History: Describe the child s speech-language problem with as much detail as possible. When was the problem first noticed? By whom? Has the problem changed since it was first noticed? How does your child typically communicate with you now (e.g. pointing, gestures, signs, crying, talking, etc.)? How long are your child s sentences? How does your child typically interact with others (e.g. spontaneously, needs prompting, etc./friendly, aggressive, shy, etc.)? Is there a family history of speech, language, hearing, or learning disabilities in the family? If so, please list. Is your child aware of communication difficulty? Yes No How does your child react when there is a communication breakdown (e.g. frustration, tantrum, give up)? SPEECH Does your child/is your child Have difficulty saying speech sounds? If so, list in comments. Have a limited number of speech sounds in repertoire? Have difficulty with non-speech movements (e.g. licking lips, blowing bubbles, sticking out tongue)? Have difficulty sequencing sounds or words? Have trouble speaking in a smooth and fluent manner? 3 2 1 Comments Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 6 of 9
LANGUAGE Does your child/is your child Able to follow familiar directions? Able to follow unfamiliar directions? Require gestures or repetition to follow directions? Able to follow multistep directions? Have difficulty understanding what is said? Have trouble answering questions? Have difficulty recalling what is said? Have difficulty expressing what he/she wants? Have difficulty finding words? Use generic language (e.g. thing, stuff) or talk around words (e.g. the stuff you use to wash your hair)? 3 2 1 Comments How long is your child typically able to attend to a self-directed activity? How long is your child typically able to attend to an adult-directed activity? SOCIAL Does your child/is your child Prefer to play alone? Have trouble getting along with others? Have a strong desire for sameness or routine? Have difficulty making eye contact? Seem sensitive to criticism? Seem to lack understanding of social rules (e.g. turn-taking, facial expressions, tone of voice, greetings, staying on topic, etc.)? Tend to be withdrawn and quiet? Tend to be aggressive? Have outbursts of anger and tantrum? Lack self-confidence? Get easily frustrated? 3 2 1 Comments Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 7 of 9
Educational History: SCHOOL SKILLS Does your child attend: Daycare/Preschool/School Current grade level: Name of current school or daycare? What district does your child attend? What is the name of your child s teacher? How does the teacher describe your child s performance? Has the teacher expressed any concerns? Does your child currently receive any school based therapy services? Does your child receive any other specialized services at school? Is your child in a regular education classroom? Does your child have a one to one assistant? If enrolled in school/preschool, is your child considered to have difficulty with any of the following? (check those that apply). Reading Spelling Finishing tasks Paying attention Restlessness Disruptive behavior Remembering information Following Directions Organizing work Requesting repetition What are your child s favorite subjects in school? What are your child s least favorite subjects in school? What is child s most difficult subject? What subject(s) are areas of strength? Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 8 of 9
PLAY/HOBBIES/EXTRACURRICULAR What are your child s favorite playthings? What does he or she do with these toys/objects? What activities does your child least enjoy? Are there any things, which your child fears or avoids? YES NO If yes, please describe. How long does your child play with one toy? Does your child play with other children? Does your child play with things by lining or piling them up (if over two years of age)? Describe: What extra-curricular activities is your child involved in? (i.e. gymnastics, soccer, swimming lessons, Scouts, musical lessons etc.) Dates involved: If no longer, reason for leaving? What do you hope to gain from this evaluation and/or treatment? What particular skill would you like your child to develop? Speech and Language Case History Form Kioko Center for Pediatric Occupational and Speech Therapy Page 9 of 9