Book an Appointment

December 17, 2017

Case History

Thank you for taking the time to answer these questions.  Please bring them to your first appointment/ evaluation.

Case History (Click for Printable Copy)

______________________________________________

Child’s Name
                                                                                                                            

Date of Birth                                Sex                              Home Phone
                                                                                                                                        

Street Address                         Apt. #                   City                      Zip Code

                    ____________________________________________

Mother’s Name                                            Work Phone       /     Cell Phone

___________________________________________________

Father’s Name                                             Work Phone      /      Cell Phone

Insurance Carrier / ID number         __________________________________________

 

Please describe any pertinent birth history.                                                                                                                                                                                                                                                                                                                  

Please fill in the age at which your child sat alone                  , crawled               , walked                , said his/her first word                    , became potty trained

Does your child attend school?                     If yes, where?                                 

Does your child receive therapy in school or privately?           ___________

If yes, in what areas and how frequently?                                                                                                                                                                                         

Please describe any speech therapy history:

 

 

How did you hear about Simon Says?  _______________________________________

What do you see as your child’s strengths and needs? Please list 2 to 3 goals that you would like us to focus on during therapy.                                                                                                                                                                                                                                                                                ____________

Please describe any pertinent medical history and/or current medical conditions, including any diagnoses your child has received and any specific diagnostic codes you would like us to use for billing purposes.                                                                                                                                                                                                                                                                               

Please list any current medications.                                                                      Please list any dietary needs/constraints.                                                                                                                                                                                            

Please list any additional information you feel we should know about your child to best serve him/her  ______________________________________________________

 

THUMB / FINGER SUCKING …..TONGUE THRUST INFORMATION

(answer only if these are areas of concern)

Describe your child’s thumb/finger sucking habit   ___________________________

 

How long has your child been sucking his/her thumb/ fingers?  ______________

Do you see your child’s tongue protrude from his/her mouth

At rest?  _________________

While eating?  ____________

While drinking?  ___________

When sleeping?  _____________

Is your child a “mouth breather”? ____________________________________________

Has your child started any orthodontic treatment yet?  If so, please describe..
______________________________________________________________________________

Please describe your main concerns with regards to your child’s sucking habits or tongue thrust behaviors.  _________________________________________________

______________________________________________________________________________

Thank you for taking the time to answer these questions.  Please bring them to your first appointment/ evaluation.