Peninsula Pediatric Therapy, Inc.

551 N. Skip Circle; Wasilla, AK 99654

907-250-1151 Phone 907-782-4202 Fax

Case History

Todays Date:

Personal Information:

Patient Name:

Date of Birth: Age: Gender: Male/ Female

Physical Address:

Mailing Address:

Home Phone: Cell/Work:

Name of Parents/Legal Guardian:

Referring Physician:

Medical Diagnosis/Issues:

Allergies:

Current Medication:

Insurance Information:

Primary Insurance Company:

Subscriber ID: Group ID:

Sponsor Name: Date of Birth:

Social Security Number:

Social History:

Primary Language: Interpreter Needed: Yes / No

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Case History Form
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Languages Spoken at Home:

Languages Spoken in Workplace/School/Community:

Child lives with ______ Both Parents; ______ Mother only; _______ Father only;

______ Guardian; ______ Grandparents; _______ Foster Parents

Educational History:

Name of School:

Address:

Phone/Fax:

Grade: Teachers Name:

Behavioral/Medical History:

Circle all that apply:

Throws things Kicks Hits

Bites Unusual Fears Breaks Glass

Spits Pinches Scratching Self/Others

Any other behavioral issues or concerns:

Hearing Issues: Wears Hearing Aids: Yes / No

Vision: Wears Glasses or Contact Lenses: Yes / No

Any Missing Teeth: Yes / No Any Jaw Problems: Yes / No

Abnormal Palate: Yes / No

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Case History Form
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Any Accidents: Yes / No

Hospitalizations: Yes / No

If yes, dates:

Surgeries: Yes / No

If yes, what types:

Any other medical issues or concerns:

Patient/ Parent/ Legal Guardian

Signed Name: