Dr. Tara McCormick OTD,OTR/L SIPT Certified
KiokoCenter, LLC Pediatric Occupational Therapy
820 Turnpike Street, Suite 104
North Andover, MA 01845
Phone: 978-681-6605
Fax: 978-681-6601
Updated October 2016
General Information:
Child’s Name:
Address:
Parent’s Name:
Employer:
Work#:
Cell #:
Email:
Names and ages of siblings:
Birth Date:
Home Phone:
Emergency Contact Person:
Emergency contact phone:
Parent’s Name:
Employer:
Work #:
Cell#:
Email:
Does child live with both parents?
Pediatrician’s Name:
Pediatrician’s Address:
Pediatrician’s Phone:
Name of Early Intervention Program (if
applicable):
Referred by (name, profession, and
address):
If in EI, what qualified your child? How
long was he/she in EI? Was he/she
discharged prior to the age of 3?
Reason for referral:
Previous evaluations (speech, neuro, etc.)?
What were the recommendations? Please
provide copies of previous evaluations.
What is primary language spoken in home?
Are there in any other languages spoken or
taught?
Does child understand 2nd language?
Speak 2nd language?
Please complete the following questions to the best of your abilities. This information is helpful to the clinician in
understanding your child’s communication and social development.
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 1 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Birth History:
Mother’s Pregnancy:
Yes
No Explain
Were there
complications during
pregnancy?
Were there
complications during
labor or delivery?
Was your child
adopted?
Was your child born
full term?
Was your child born
premature?
Was your child born
small for gestational
age (SGA)?
Was your child breech
(feet first)?
Were forceps used?
Was suction required?
Were there any birth
injuries?
Was intensive care
hospitalization
required?
Was your child
jaundiced?
If known, Apgar rating
at 1 and 5 minutes?
Additional
information regarding
birth?
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 2 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Medical History:
Medical diagnosis (if any)_________________________________________________________
Date of diagnosis _________________________ Given by _______________________________
Has your child had a hearing test? __________Yes
________No
Dates:____________________ Results:_________________________________
Has your child had a vision test? ___________Yes
_________No
Dates: ___________________ Results:__________________________________
Does your child have any assistive devices (e.g. glasses, hearing aides, communication devices,
wheelchair,?_____________________________________________________
Has your child had any of the following?
No
Yes Date(s)
Explain
Childhood diseases
Major illnesses
Congenital abnormalities
Surgery
Serious injury or injuries
Ear infections
Tubes in ears
Tonsils or adenoids removed
Allergies (food or medications)
Allergies (environmental)
Seizures
Other
Current medications
Dosage
Frequency of dosage
Are there any medical precautions the therapist should be aware of when working with your child?
_________________________________________________________________
Any negative reactions to medications in the past?
_________________________________________________________________
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 3 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Developmental History:
Developmental Milestones:
Approximate Age Reached
Comments or any unusual
habits
Speak first words (no, mom,
doggie)
Combine words (me go,
daddy shoe)
Speak in sentences (I go
now, Mommy at work)
Chew solid foods
Drink from a cup
Feed him/herself
Sit alone
Crawl
Walk
Dress him/herself
Use toilet
Did/does your child……..
Yes
No
Please describe
babble as an infant?
respond to people and faces as an
infant?
have difficulty walking, running, or
participating in activities which
require muscle coordination?
have any feeding problems (e.g.
problems with sucking, swallowing,
drooling, chewing, etc.)?
snore or have difficulty sleeping?
show a lack of interest in
communicating?
show a lack of fear of dangers?
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 4 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Sensory and Motor History:
Comment as desired and cross out any questions that do not apply to your child.
ORAL MOTOR/FEEDING
Does your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Drool without noticing?
Suck through a straw?
Stuff food?
Eat in a sloppy manner?
Tend to be slow in eating?
Avoid foods or textures? If so, please list.
Have preferred foods or textures? If so, please
list.
Have difficulty chewing or swallowing?
Keep mouth open most of the time or breathe
through the mouth?
Other?
3 2
1 Please describe
3 2
1 Please describe
3 2
1 Please describe
AUDITORY
Does your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Have difficulty hearing in background noise?
Get distracted by sounds or noises?
Have difficulty localizing sound?
Mishear words (e.g. cut for cup)?
Request repetition or say “huh?” frequently?
Have a short auditory attention span? Fatigue
easily when listening?
Other?
MOTOR/SENSORY
Does your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Have any sensory or tactile issues?
Have any balance issues?
Avoid certain types of movement (e.g. climbing,
swinging)?
Seek out certain types of movement?
Demonstrate appropriate gross motor skills?
Demonstrate appropriate fine motor skills?
Demonstrate any unusual behaviors (e.g. headbanging, hand-flapping, etc.)?
Other?
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 5 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Communication History:
Describe the child’s speech-language problem with as much detail as possible.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
When was the problem first noticed? By whom?
______________________________________________________________________________________________
Has the problem changed since it was first noticed?
______________________________________________________________________________________________
How does your child typically communicate with you now (e.g. pointing, gestures, signs, crying, talking, etc.)?
__________________________________________________________________________________________
How long are your child’s sentences?
___________________________________________________________________________________________
How does your child typically interact with others (e.g. spontaneously, needs prompting, etc./friendly, aggressive,
shy, etc.)?
______________________________________________________________________________________________
______________________________________________________________________________________________
Is there a family history of speech, language, hearing, or learning disabilities in the family? If so, please list.
______________________________________________________________________________________________
______________________________________________________________________________________________
Is your child aware of communication difficulty? ___________Yes ___________ No
How does your child react when there is a communication breakdown (e.g. frustration, tantrum, give up)?
______________________________________________________________________________________________
______________________________________________________________________________________________
SPEECH
Does your child/Is your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Have difficulty saying speech sounds? If so, list
in comments.
Have a limited number of speech sounds in
repertoire?
Have difficulty with non-speech movements
(e.g. licking lips, blowing bubbles, sticking out
tongue)?
Have difficulty sequencing sounds or words?
Have trouble speaking in a smooth and fluent
manner?
3 2
1 Comments
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 6 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
LANGUAGE
Does your child/Is your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Able to follow familiar directions?
Able to follow unfamiliar directions?
Require gestures or repetition to follow
directions?
Able to follow multistep directions?
Have difficulty understanding what is said?
Have trouble answering questions?
Have difficulty recalling what is said?
Have difficulty expressing what he/she wants?
Have difficulty finding words?
Use generic language (e.g. thing, stuff) or talk
around words (e.g. the stuff you use to wash
your hair)?
3 2
1 Comments
How long is your child typically able to attend to a self-directed activity? ___________________________________
How long is your child typically able to attend to an adult-directed activity? _________________________________
SOCIAL
Does your child/Is your child…
3 - Often 2 - Sometimes
1 - Rarely/Never
Prefer to play alone?
Have trouble getting along with others?
Have a strong desire for sameness or routine?
Have difficulty making eye contact?
Seem sensitive to criticism?
Seem to lack understanding of social “rules”
(e.g. turn-taking, facial expressions, tone of
voice, greetings, staying on topic, etc.)?
Tend to be withdrawn and quiet?
Tend to be aggressive? Have outbursts of anger
and tantrum?
Lack self-confidence?
Get easily frustrated?
3 2
1 Comments
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 7 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
Educational History:
SCHOOL SKILLS
Does your child attend: Daycare/Preschool/School _________________ Current grade level: _______________
Name of current school or daycare? ______________________________________________________________
What district does your child attend? _____________________________________________________________
What is the name of your child’s teacher? _________________________________________________________
How does the teacher describe your child’s performance? ____________________________________________
___________________________________________________________________________________________
Has the teacher expressed any concerns? __________________________________________________________
___________________________________________________________________________________________
Does your child currently receive any school based therapy services? ___________________________________
Does your child receive any other specialized services at school? _______________________________________
Is your child in a regular education classroom? _____________________________________________________
Does your child have a one to one assistant? _______________________________________________________
If enrolled in school/preschool, is your child considered to have difficulty with any of the
following? (check those that apply).
Reading____________
Spelling ___________
Finishing tasks____________
Paying attention __________ Restlessness _________ Disruptive behavior _______
Remembering information _________ Following Directions ____________
Organizing work ______________
Requesting repetition _______________
What are your child’s favorite subjects in school?
What are your child’s least favorite subjects in school?
What is child’s most difficult subject?
What subject(s) are areas of strength?
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 8 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________
PLAY/HOBBIES/EXTRACURRICULAR
What are your child’s favorite playthings?
What does he or she do with these toys/objects?
What activities does your child least enjoy?
Are there any things, which your child fears or avoids?
If yes, please describe.
How long does your child play with one toy?
Does your child play with other children?
Does your child play with things by lining or piling them
up (if over two years of age)?
Describe:
What extra-curricular activities is your child involved in?
(i.e. gymnastics, soccer, swimming lessons, Scouts,
musical lessons etc.)
YES
NO
Dates involved:
If no longer,
reason for
leaving?
What do you hope to gain from this evaluation and/or treatment?
What particular skill would you like your child to develop?
Speech and Language Case History Form – Kioko Center for Pediatric Occupational and Speech Therapy
Page 9 of 9
Child’s Name:_______________________________ DOB: _______________ Date:____________________