Leetaloo Pediatric Therapy

CHILD HISTORY FORM

General Information
Date of Evaluation:_____________
Child’s Name:_______________________________ Male / Female? Date of Birth:_____________
Parents/Guardians:___________________________________________________________________
____
Address:__________________________________________________________________________
_______
Phone #:________________________________ Cell Phone
#:___________________________________
Who referred child for occupational therapy services? ________________________________________
Has your child ever received therapy in the past? _____________________________________________
If Yes, where and what services?
___________________________________________________________
Has your child been given a medical diagnosis?______________________________________________
**** Thank you so much for taking the time to fill out this questionnaire. In order to accurately determine your
child’s needs, all aspects of his/her life is necessary to get the big picture. Your input is invaluable as you know your
child better than anyone else. Again, thank you for providing this very necessary information!!!!

A. Parent’s Hopes:
1. What do you see as your child’s strengths?
________________________________________________________________________________
________
________________________________________________________________________________
________
2. What do you hope will be gained by having your child seen today?
________________________________________________________________________________
____________
________________________________________________________________________________
____________

B. Birth History:
Is your child adopted? If so, what age was your child at the time of the adoption and was there any specific
instructions given? ___________________________
Was prenatal care initiated? If so, at what month?__________________________________
Any complications during pregnancy? If so,please
explain:___________________________________________
My pregnancy was: ___ weeks Birth weight was: __________________
Were there any complications/concerns during birth? Yes____ No____
If yes, please explain: _____________________________________________________________
Was assistance (i.e. forceps, vacuum, oxygen) required to deliver your baby? Yes____ No____
If yes, please explain: _____________________________________________________________
As an infant, did your child ever experience (please check): jaundice ____seizures _____cyanosis______
plagiocephaly __________torticollis_____anoxia___________
Pneumonia______any other neurological
condition_____________________________________________________
How long were you in the hospital? _________________________________
How long was your child in the hospital? ____________________________
C. Medical History
Is there a history of any illness/injury/surgeries? Yes_________ No___________
If yes, please explain: _____________________________________________________________
Does your child have any allergies? Yes____ No____
If yes, please explain if they are managed, and any behavior exhibited as a result: _____________
________________________________________________________________________________
______
Does your child currently take any medications? Yes____ No____
 Leetaloo Pediatric Therapy

If yes, please explain the medication, for what condition the medicine is being taken, and any
Was your child breast fed? If so, where there any complications?
_____________________________________________
Please describe your child’s sleeping patterns as an
infant___________________________________________________
Does your child have a history of ear infections?________________________________
Has your child ever needed tubes?____________________________________________
Is your child hearing impaired?________________________________________________
Is your child vision impaired?__________________________________________________
Does your child exhibit any of the following on a regular basis (please circle):
Diarrhea Stomachache Vomiting Headache Constipation Earache
________________________________________________________________________________
_______________________
D. Previous Interventions (if applicable otherwise skip section)
Please list the professionals that your child has seen with contact information:
Psychologist________________________________ Neurologist
_______________________________
Occupational Therapist _____________________ Physical
Therapist___________________________
Speech Therapist___________________________ Allergy Specialist
___________________________
Sleep Specialist_____________________________
Psychiatrist_________________________________
Social Worker_____________________________ Educational
Specialist_________________________
Developmental Optometrist/ Ophthalmologist________________________________________________
Other: _____________________________________________________________
What have you been told by doctors, teacher and/or others about your child’s abilities and needs?
________________________________________________________________________________
________
________________________________________________________________________________
________
________________________________________________________________________________
_______
E. Developmental History: (best estimate)
Please indicate when your child did the following:
Approximately when did the following begin?
Sitting ____________________ Babbling _____________________
Crawling __________________ First word ____________________
Walking __________________ combining word _______________
F. Family/Social /School History:
Siblings/Ages:
__________________________________________________________________________
Any family supports available (ex. Family, friends, neighbors, babysitters? __________________________
________________________________________________________________________________
______
Have there been any significant changes in your family recently (moving, births, deaths, divorce)?
________________________________________________________________________________
______________________________________
Home environment- house/apartment, cluttered/ neat, individual bedroom or shared,
etc______________________________________________________________________________
_______________________________________
Are there any religious, spiritual, ethnic customs, etc that you would like for us to recognize?
________________________________________________________________________________
_______________________________
Please describe your child’s typical play skills. Include information about the ages of the people your
child chooses to play with, if your child chooses to be a leader, a follower, or a loner, how many people your
 Leetaloo Pediatric Therapy

child is comfortable playing with at once, whether your child prefers a few close friends or a lot of
“acquaintances”.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________
School Information (if attending- otherwise skip section)
What is the name of school your child is attending:____________________________________________
Teacher’s Name: ______________________________________________________________
Do I have permission to contact the teacher if necessary:____________

Has your child ever been held back a grade? Yes No

My child's grades in school are:

Above average (A,B) Average (C) Below average (D,F)

My child's favorite subject in school is:

Least favorite:
My child exhibits:

Difficulty reading Difficulty spelling Difficulty following directions

Daydreaming during class Overall frustration with learning

Poor handwriting/letter formation Poor memory

Right-left confusion/directionality problems Poor or late letter recognition

Poor organization Poor concentration

Is your child in a special class or receiving any support services (specify)? __________________________
________________________________________________________________________________
______
Has your child had any formal evaluations/testing? _____________________________________________
If so, what and when?
____________________________________________________________________
G. Behavioral/Emotional/ Communication History:
What discipline works best for your child? Please
describe____________________________________________________________
Please use the following scale to describe your child’s behavior to the following items:
1- Never or rarely exhibits this behavior
2- Occasionally exhibits this behavior
3- Exhibits this behavior as much as is typical for a child of this age
4- Exhibits this behavior somewhat more often than expected
5- Very frequently exhibits this behavior

1 2 3 4 5 Compliant
1 2 3 4 5 Displays affection towards others
1 2 3 4 5 Displays aggression towards self
1 2 3 4 5 Irritable
1 2 3 4 5 Cries easily
1 2 3 4 5 Seems happy
1 2 3 4 5 Seems immature for age
 Leetaloo Pediatric Therapy

1 2 3 4 5 Displays rapid mood swings

1 2 3 4 5 Seems independent
1 2 3 4 5 “Baby talks”
1 2 3 4 5 Seems to need a lot of comfort and nurturing
1 2 3 4 5 Seems impulsive
1 2 3 4 5 Difficult to discipline
1 2 3 4 5 Blames others for own mistakes
1 2 3 4 5 Seems remorseful
Communication
1 2 3 4 5 Initiates eye contact when greeting someone
1 2 3 4 5 Initiates eye contact when requesting information
1 2 3 4 5 Sustains eye contact
1 2 3 4 5 Takes Turns
1 2 3 4 5 Interacts with peers
1 2 3 4 5 Participates in conversations
1 2 3 4 5 Responds to verbal information in a timely manner (little lag in response time)
If your child is non-verbal, please describe the frequency and types of vocalizations your child uses
________________________________________________________________________________
____________
________________________________________________________________________________
_______
If your child is non-verbal, please describe how your child communicates and give examples
________________________________________________________________________________
____________
________________________________________________________________________________
____________
H. Self care/ Independent Life skills (if appropriate)
Please rate on 1-4 (1=no help 2= slight help 3= a lot of help 4= child is dependent)
Tooth brushing_____Hair washing____ Bathing_______Dressing_______Sits for meals______ Toileting
______
Keeps track of own belongings______ Organizes homework_________
I. Arousal/Attention/Self-Regulation:
Please indicate with a Y for yes or N for no
Is an early morning riser________ Awakens during the night________ Has difficulty falling asleep______ Is
irritable upon waking_____
Wets bed_________Attends to toys _______Attends when in new environments_______ pays attention at
school_________
Independently explores_________ Enjoys rough house play________
J. Balance/Body Awareness Praxis:
Please indicate with Y or N
Initiates new activities________Understands how to play with new toys________Plays with the same toy in a
variety of ways________
Able to perform sequential tasks_____ Plays on playground equipment (slides, jungle gym, monkey bars, etc.)
_________
Is your child afraid of heights or movement?________Jumps_______Swings_____ ___Seems aware of safety
concerns______
Can your child descend and climb stairs______ __Takes risk _______Does your child get motion sickness in the
car?___________
K. Sensory Components
1. Please describe your child’s sensitivity to touch. Include information about your child’s behavior
regarding being touched, any clothing preferences your child might have, how your child uses
touch to explore, etc.
________________________________________________________________________________
____
________________________________________________________________________________
____
________________________________________________________________________________
____
 Leetaloo Pediatric Therapy

2. Please describe your child’s sensitivity to movement. Include information about the types of movement
your child likes and dislikes, the frequency with which your child seems to seek movement, your
child’s behavior regarding being moved or off of the ground, etc.
________________________________________________________________________________
____
________________________________________________________________________________
____
________________________________________________________________________________
____
3. Please describe your child’s sensitivity to sound. Include any types of sounds your child particularly
enjoys or particularly dislikes, your child’s ability to filter out irrelevant sounds, your child’s behavior
regarding loud sounds, etc.
________________________________________________________________________________
____
________________________________________________________________________________
____
________________________________________________________________________________
____
4. Please describe your child’s visual attention. Include information about sensitivity to light, ability to
attend to relevant visual information, ability to sustain visual attention, which typically engages
your child’s visual attention.
________________________________________________________________________________
____
________________________________________________________________________________
____

Self-Care/Daily Routines
1. Please describe a typical mealtime with your child. Include where, what, and how your child eats, your child’s
typical appetite, the number of meals and snack your child has each day, your child’s behavior during
mealtimes, etc.
___________________________________________________________________________
________________________________________________________________________________
________

________________________________________________________________________________
________
________________________________________________________________________________
________
2. Please describe how your child typically gets dressed. Include the types of clothing your child wears, how
independent your child is with his or her clothing, how long it takes your child to dress, your child’s behavior
during dressing, etc.
_______________________________________________________________________
________________________________________________________________________________
________
________________________________________________________________________________
________
________________________________________________________________________________
________
3. Please describe a typical bath time for your child. Include your child’s level of independence in bathing, your
child’s like or dislike for bath time, your child’s behavior during bath time, etc.
________________________________________________________________________________
________
________________________________________________________________________________
________
________________________________________________________________________________
________
 Leetaloo Pediatric Therapy

________________________________________________________________________________
________
5. Please describe your child’s toileting skills. Include level of independence, frequency of occurrences of
bed wetting, frequency of occurrences of daytime bowel and bladder accidents, awareness of
toileting needs, etc.
______________________________________________________________________
________________________________________________________________________________
________
________________________________________________________________________________
________
________________________________________________________________________________
________
6. Please describe how your child makes transitions between people or environments. Include level of
independence during transitions, need for transitional objects, need for advance preparation about
schedule changes, etc.
________________________________________________________________________________
________
________________________________________________________________________________
________
________________________________________________________________________________
________
7. If applicable, please describe how your child completes homework. Include level of independence, need for
breaks, need for external supports (music, food, etc.), the amount of time typically needed, etc.
________________________________________________________________________________
__
-6-
________________________________________________________________________________
__
________________________________________________________________________________
___
8. Please describe your child’s abilities to keep track of personal belongings.
________________________________________________________________________________
_______
________________________________________________________________________________
________
________________________________________________________________________________
________
9. Please describe your child’s ability to independently organize personal belongings (homework,
bedroom, desk, etc.
________________________________________________________________________________
__
________________________________________________________________________________
__
________________________________________________________________________________
__
10.
Arousal/Attention/Self-Regulation
Please use the following scale to describe your child’s behavior
1- Never or rarely exhibits this behavior
2- Occasionally exhibits this behavior
3- Exhibits this behavior as much as is typical for a child of this age
4- Exhibits this behavior somewhat more often than expected
5- Very frequently exhibits this behavior
-1 2 3 4 5 Is an early morning riser
-1 2 3 4 5 Awakens during the night
-1 2 3 4 5 Has difficulty falling asleep
-1 2 3 4 5 Is irritable upon awakening
-1 2 3 4 5 Wets bed
 Leetaloo Pediatric Therapy

-1 2 3 4 5 Attends to toys
-1 2 3 4 5 Attends at school
-1 2 3 4 5 Attends in new environments
-1 2 3 4 5 Able to independently sustain attention
-1 2 3 4 5 Independently Explores
-7-
Please describe the following (include behaviors your child exhibits that you think are significant,
And “tricks” you use to help your child during these times, etc):
A typical bedtime routine:
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________
A typical nights sleep:
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________
A typical wake-up routine:
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________________________
____________
________________________________________________________________
Does your child seem irritable at predictable times of the day? If yes, please describe the times of the day when
your child seems irritable and the events that seem likely to trigger irritability.
________________________________________________________________________________
____________
________________________________________________________________________________
____________
_______________________________________________________________________
Does your child seem happier or more cooperative at predictable times of the day? If yes, please describe the times
of the day when your child seems happiest and most cooperative and the events that seem likely to precede these
behaviors.
________________________________________________________________________________
____________
________________________________________________________________________________
____________
_______________________________________________________________________
Please describe how your child approaches a new environment

Please describe any strategies your child uses to help himself or herself sustain focused attention