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

      YesNo

    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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    Advanced Therapy Solutions
    690 E Warner Road #105
    Gilbert, AZ 85296

    Office Phone: 480.820.6366
    Office Fax: 480.820.0462

    Hours of Operation:
    Monday to Friday
    8:00am to 5:00pm