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)  
    Speech
    Physical
    Occupational
    Vision
    Music
    Feeding
    Habilitation
    Other

    Allergies

    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:  Reading  Math        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.