Patient Case History Form

DEVELOPMENTAL MILESTONES
Please indicate the age at which your child reached the following developmental milestones and describe any problems observed. (If milestone has not been reached or is not applicable, write N/A. If it's emerging, write "E").
Sat Unsupported:
Walked alone:
First ate solids pureed
Toilet-trailed for bladder control:
Stayed dry through the night
Undressed self
Drank from a cup
Crawled
Ran
Held bottle
Toilet-trained for bowel control
Rolled Over
First ate finger foods
Dressed self without help
Were there concerns about your child's physical or mental growth during the first 18 months? If so, please describe. If not, write N/A.*
Does your child...
- Choke on food or liquids?
- Currently put toys/objects in his/her mouth?
- Brush his/her teeth and/or allow brushing?
(Check all that apply.)

SOCIAL HISTORY
Does your child get along with other children?*
- Yes
- No
What are the ages of your child's most frequent playmates?
Does your child present any behavioral problems? If so, please describe? (Explain At Home, At School/Daycare, In The Neighborhood/Community.)

SPEECH-LANGUAGE - HEARING
Do you believe your child has a speech problem?*
- Yes
- No
If you believe your child has a speech problem, please describe:
Has your child ever had a speech evaluation or ever had speech therapy?*
- Yes
- No
If your child has ever had a speech evaluation or speech therapy, where and when?
If your child has had a speech evaluation or speech therapy, what were you told?
If your child was receiving speech therapy, what were they working on?
Has your child ever received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.?)
- Physical therapy
- Occupational therapy
- ABA therapy
- counseling
- vision
If your child has ever received any other evaluation or therapy, please describe:
Is your child aware of or frustrated by any speech/language difficulties? If so, please describe:
What do you see as your child's most difficult problem(s) in the home?*

IDENTIFYING INFORMATION