690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

CASE HISTORY

Does your child have a medical diagnosis? (List if applicable)
YesNo      

Has the child received therapy in the past? (Check if applicable)
SpeechPhysicalOccupationalVisionMusicFeedingHabilitationOther

Is there a history of allergies?

YesNo

If there is a history of allergies, please note which allergies, the reaction if exposed, and the severity on a scale of 1-10 (1= very mild, 10= most severe).

Birth History

Delivery:  VaginalCesarean      

Did the child have any difficulties sucking?  YesNo

Was the child a good eater as an infant?  YesNo

Was the mother in good health and nutrition during the pregnancy?  YesNo

Did the mother smoke, drink, or do drugs, during pregnancy?  YesNo

At what age did your child achieve the following:

Does your child experience the following:

Poor Attending Skills:YesNo        Easily Distracted:YesNo        Aggressive Behaviors:YesNo

Resistance To Structure:YesNo        Has Social Skill Concerns:YesNo        Anxiety:YesNo

Sensitivity To Sound:YesNo        Object To Being Touched:YesNo        Severe Fear Of Something:YesNo

Picky Eater:YesNo

Is there a history of:

Asthma:YesNo        Have an inhaler?YesNo        Seizures:YesNo        Currently experiencing regularly?YesNo

Head Injuries:YesNo        

Family With Learning Disability/Difficulties:YesNo        

Family With Speech/Language Impairment:YesNo        

Family With Hearing Impairments:YesNo        

Recurrent Ear Infections:YesNo        Pressure-Equalized Tube Placed:YesNo        

Hearing Loss:YesNo                Hearing Aids:YesNo

Vision Loss/Correction:YesNo                Wear Glasses/Contacts:YesNo

School Information:

Does child perform at grade level in:ReadingMath        504/IEP:YesNo

Consent For Care:

I, , agree and give my consent for Advanced Therapy Solutions to furnish medical care and treatment considered necessary and proper in evaluating and treating my child, , and their conditions.

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