Child Case History
General Information
Email address:*
*
example@example.com
Case History Completed By
First Name
Last Name
Child's Name
First Name
Last Name
Pronouns to be used on report for child:
She/Her
He/Him
They/Them
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's age:*
*
Birthdate
-
Month
-
Day
Year
Date
Grade
School:*
*
Handedness:*
*
Left
Right
Evaluation requested by:
*
School
Therapist
Parent
Other
Parent/Guardian #1 name
First Name
Last Name
Parent/Guardian #1 preferred phone number:
Please enter a valid phone number.
Parent/Guardian #1 email address:
*
example@example.com
Parent/Guardian #2 name
First Name
Last Name
Parent/Guardian #2 preferred phone number:
Please enter a valid phone number.
Parent/Guardian #2 email address:
example@example.com
Back
Next
Save
Current Concerns
Please be generous with details when answering the next two questions!
What general and/or specific concerns do you have regarding your child’s and/or your functioning in school or at home?
*
What do you hope to obtain from this evaluation?
*
Academic History
Chronological history of school attendance.
List schools attended.Include grades/ages attended, whether the school was public or private, and whether your child received special education services. List whether your child had an IEP, 504, or RTI.
School
Grades/Ages
Public or Private?
Special Services?
IEP/504/RTI?
1
2
3
Please describe any current academic difficulties:*
*
Has the child been held back a grade in school or skipped a grade in school?*
*
Yes
No
Please describe:
Chronological history of difficulties:
When were concerns first noticed? Age of child? By whom?*
*
Please list all previous evaluations.Include date of assessment, who conducted the assessment, the type of evaluation (psychoeducational, speech/language, occupational therapy, neuropsychological), and the results or diagnosis.
Date
Conducted By
Type of Evaluation
Results/Diagnosis
1
2
3
Back
Next
Save
Previous Support Provided
(e.g. tutoring, speech/language, OT, therapy)
Please list date, and grade when support was provided.*
*
Was the support through school? If so, was it an IEP, 504, or RTI?
If support was private, please list whether it was tutoring, therapy, or medications.
Vision
Does your child have any known vision problems?*
*
Yes
No
Please check all that apply:
Wears glasses
Wears contacts
Nearsighted
Farsighted
When was your child's vision last tested?(Approximate date is fine)
-
Month
-
Day
Year
Date
Do you have any concerns related to the child's vision?
Auditory Behavior/Oral Language
Do you have concerns about your child's comprehension of language?*
*
Yes
No
Please explain:
Does your child enjoy being read to?*
*
Yes
No
Does your child have any unusual pronunciations or are there any sounds that they have trouble making?*
*
Yes
No
Please explain:
Does your child have any difficulty pronouncing certain words?*
*
Yes
No
Please explain:
Does your child's vocabulary seem appropriate for their age?*
*
Yes
No
Does your child ever have difficulties thinking of the word they want to say?*
*
Yes
No
Please explain:
Can your child follow oral directions?*
*
Yes
No
Reading
Describe problems with reading, if any, at home or at school:
What types of books does your child enjoy reading?*
*
(Doesn't like to read anything)
Action / Suspense
Graphic Novels / Manga / Comics
History / Historical Fiction
Humor
Non Fiction
Sci Fi
YA Fiction
Other
What other types of reading?
Writing
Describe writing problems, if any, at home or at school?
What is the quality of your child's handwriting?*
*
Strong
Average
Weak
Unsure
What is the quality of your child's spelling?*
*
Strong
Average
Weak
Unsure
What is the quality of your child's story writing?*
*
Strong
Average
Weak
Unsure
Can your child type?*
*
Yes
No
Can your child type while looking away from the keyboard?*
*
Yes
No
Mathematics
How are your child's math facts?*
*
Strong
Average
Weak
Unsure
How are your child's math reasoning skills (problem solving, word problems)?*
*
Strong
Average
Weak
Unsure
How are your child's practical math skills (making change, measuring, altering recipes)?*
*
Strong
Average
Weak
Unsure
Attention and Organization
Is your child easily distracted?*
*
Yes
No
Please explain or provide examples:
How are your child's organizational skills?*
*
Strong
Average
Weak
Unsure
How is your child's sense of time?*
*
Does your child have trouble shifting from one thought or activity to another?*
*
Yes
No
Sometimes
Please describe struggles with attention and organization, if any:
Back
Next
Save
Family History
Parent/Guardian #1 occupation:*
*
Parent/Guardian #1 education:*
*
Parent/Guardian #1 - Any learning problems at school? Please list:
Are there any medical or psychiatric conditions in the family or extended family? If yes, please list:
Parent/Guardian #2 occupation:
Parent/Guardian #2 education:
Parent/Guardian #2 - Any learning problems at school? Please list:
Are there any medical or psychiatric conditions in the family or extended family? If yes, please list:
Back
Next
Save
Siblings
Does your child have siblings?*
*
Yes
No
Please list all the siblings below
Sibling Name
Age & Grade
Learning Difficulties, if any
Attention Concerns, if any
1
2
3
Back
Next
Save
Child's Medical History
Current pediatrician name:
First Name
Last Name
Would you like a copy of the report mailed to your pediatrician?*
*
Yes
No
Decide Later
Current pediatrician address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pregnancy, Birth, and Medical History
Was your child adopted?
Yes
No
At what age?
Length of pregnancy?
Please explain problems during delivery, if any (e.g. bleeding, infections, diabetes):
Birthweight:
Please list any medical conditions your child has had (e.g. measles, mumps, chicken pox, allergies, meningitis, hypothyroid, diabetes, ear infections, attention deficit disorder):
Please list other medical concerns (e.g. inattentiveness, headaches, distractibility):
What medications are prescribed?
Back
Next
Save
Developmental History / Motor Development
At what age did your child learn to walk alone?*
*
At what age did your child use their first words?*
*
Is there now, or have there ever been, bedwetting problems?*
*
Yes
No
Please describe:
Please explain noticeable delays in self-help skills (i.e. dressing, eating), if any.
Does the child have a poor sense of direction?*
*
Yes
No
If "yes" please describe:
Any problems determining left and right?*
*
Yes
No
If "yes" please describe:
How is your child's hand-eye coordination
Strong
Average
Weak
Social Emotional Development
How is your child's relationship with parent/guardian #1?*
*
How is your child's relationship with parent/guardian #2?
How is your child's relationship with siblings or close peers?*
*
Does your child have many friends?*
*
Yes
No
Would you describe your child as a leader or follower?*
*
Leader
Follower
How would you describe your child's self-concept?*
*
(How they see themselves?)
Does your child's level of maturity seem appropriate for their age?*
*
Yes
No
Maybe
Describe your child's self-conception of their difficulties:*
*
Please describe your child's temperament, fears, sense of humor, behavior:*
*
Hobbies and Extracurricular Activities
Please list your child's extracurricular activities:
What are your child's responsibilities at home?
Is your child successful at meeting their responsibilities?
Yes
No
Sometimes
Additional Concerns
Please list any additional concerns or information that might be helpful in this evaluation.
Save
Submit Case History
Should be Empty: