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Washington, DC • 202-363-8255

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FUNdamentals and Building Blocks Therapy Case History Form

Please fill out the information below. You will have the opportunity to review your form before submitting. If you prefer to print the form and deliver it in person or by mail, Click Here to download printable form.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Childs Name*

First Middle Last

Nickname

Birth Date*

Month

Day

Year

Age

Address*

Street Address Address Line 2 City Select a State ZIP Code

Lives With

Guardian 1*

First Last

Address*

Address same as child

Street Address Address Line 2 City Select a State ZIP Code

Home Phone

Work Phone

Cell Phone

Email*

Guardian 2

First Last

Address

Address Same As Child

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

Billing Email Address (invoices will be sent via email to this address)*

SIBLING INFORMATION

Name

First Last

Age

Related Difficulty

Name

First Last

Age

Related Difficulty

Name

First Last

Age

Related Difficulty

Other individuals living in the home

Other Language spoken in the home

BIRTH HISTORY

Medications Taken during pregnancy or labor

Birthplace

Doctor

Birth Weight

Length of Labor

Labor

Normal

Induced

C-Section

Length of Hospital Stay

List any special care or precautions taken (bed rest, oxygen, jaundice, etc.)

MEDICAL HISTORY

Pediatrician

Phone

Address

Street Address Address Line 2 City Select a State ZIP Code

Date of last physical

Month

Day

Year

Results

Date of last Hearing Screening

Month

Day

Year

Results

Date of last Vision Screening

Month

Day

Year

Results

Has your child ever been given a medical diagnosis? If so, what?

Allergies (please note reactions to allergies if applicable)

Current Medications:

Please Check all that apply:

Frequent colds

Frequent Respiratory infections

Frequent ear infections

Hearing Loss

Chicken Pox

Excessively high fevers

Mono

Spinal Meningitis

Epilepsy

Cerebral Palsy

Traumatic brain damage

Seizures

Other

Other Description

Please provide any information pertinent to checked items

Hospitalizations

Other Professionals Working With Your Child

Name

Phone

Name

Phone

Name

Phone

Motor Development

Note age of:

Sat up

Crawl

Walk

Jump ( 2 foot )

Potty Trained

Check if appropriate:

Trips or falls easily

Fear of heights

Afraid of climbing

Difficulty grasping items

Clumsy

FEEDING DEVELOPMENT

Note Age Of:

Breast Fed

Drinking from a Bottle

Drinking from a Cup

Using Utensils

Eating Table Food

Does your child have difficulties sucking, swallowing, chewing, drinking from a cup, drinking fron a straw, eating different textures? (Explain)

Strong food preferences?

Avoids or dislikes certain foods

Food Allergies

SPEECH AND LANGUAGE DEVELOPMENT

Note Age Of:

Babbling (bababa)

Jargon (linking babbling together)

First Words

Combining words

Any time at which your child's speech and language or learning development regressed or ceased? (please explain)

Intelligibility of speech ( approximate )

% to family

% to others

Please describe current concerns related to speech, language or learning development

Has the child had a speech and language evaluation previously? If yes, please note the place and findings.

Has the child had a speech and language therapy in the past? If yes, please note the place and length of treatment.

Is the child aware of difficulties he/she may be experiencing?

PSYCHOLOGICAL AND NEUROLOGICAL DEVELOPMENT

Has your child had a psychological assessment? (If yes, please note reason, date and place and a brief summary )

Has your child had a neurological evaluation? (If yes, please note reason, date and place and a brief summary )

Untitled

Nervous

Hyperactive

Sleepless

Wets Bed

Nightmares

Sad

Withdrawn

Shy

Easily Upset

Destructive

Aggressive

Temper Tantrum

Head Banging

Swaying

Tics

Anxiety

Sensitive to sound in the enviroment

Underreactive to Sound

Short attention span

Sensitive to being touched

Underreactive to Being Touched

Fearful of new situations, people, enviroment

Preservative behaviors ( doing something over and over )

EDUCATIONAL DEVELOPMENT

Current Grade

Teacher

School

Previous Schools Attended

Specific concerns regarding school

Special services received at school

Special services received outside of school

Child's attitude toward school and learning new things

What are you hoping to gain/explore from evaluation or therapy?

Please note any concerns or related issues not covered in this case history

INSURANCE INFORMATION

We will not bill your insurance company directly, but we can put this information on your bill to make the process easier for you.

Do you plan on filing for insurance reimbursement?

Yes

No

Name of Insurance Company

Name of Insured

Policy or authorization number

FINAL INFORMATION

It may be helpful to keep a 2 day log of foods your child eats and bring this information to your first appointment.

Who were you referred by?

Preferred therapy days:

Preferred therapy times:

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