Child Clinic History - Essential Therapy Services

Personal Information - Step 1 of 11

Child Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of birth

Child's Age

Place of birth

City of Birth

Citizenship

Referred by

Main concern: (Describe it briefly)

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Were you given any medication during your pregnancy?

Medications names

Did you have any serious illness, accident, or injury during your pregnancy?

Describe the illness, accident, or injury during your pregnancy

Were you under stressful or emotionally unstable conditions during your pregnancy?

Were there any other complications or unusual circumstances during your pregnancy?

Describe the complications or unusual circumstances during your pregnancy?

family Main the

Was the child born at full term?

Number of hours to give birth:

Type of childbirth

Natural
Cesarean birth

Birth Weight

Please write the birth weight in Pounds

Were there any complications during or immediately after delivery?

Complications during or immediately after delivery

Name of the hospital where the child was born

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Name of the child's pediatrician:

Pediatrician Address

Address Line 1

City

State

Zip Code

Pediatrician Phone

Date and name of the ophthalmologist or optometrist who completed the last eye exam

Is your child currently taking any medication?

Reason for medication

Child's Medication

Dosage

Indicated by

How long have you been receiving this medication?

Allergies

Does your child suffer from frequent colds, ear infections, or other illnesses?

Have you had seizures, high fever, accidents, or been hospitalized?

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At what age did the child hold up their head while lying face down?

At what age can a child sit up on their own?

At what age does a child crawl?

At what age did the child stand up on his own?

At what age did the child walk without help?

At what age did the child eat with a spoon alone?

At what age did the child dress and undress himself?

At what age does a child gain control of their bladder and bowels while awake?

At what age does a child gain control of their bladder and bowels while asleep?

Do you think your child has developed gross/fine motor skills adequately?

Describe the issue with the gross/din motor skills

Which hand does the child prefer to use?

Left
Right

Has the child ever shown difficulty chewing or swallowing?

Does he drool too much?

Please explain the difficulties

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At what ages did the child develop the following forms of articulation?

At what age did the child begin to babble?

Example of babbling?

At what age did the child say their first word?

What was the first word?

At what age did he say a combination of two words?

What was the combination of the two words?

At what age did the child begin to say short, complete phrases?

What was the phrase?

Does the child show any difficulty in understanding when spoken to?

Does the child frequently/occasionally/or never articulate words?

Briefly describe some of the verbal phrases the child frequently uses?

Does the child use gestures as an alternative or additional form of communication?

Is the child able to make himself understood by other family members?

Can the child make himself understood by close friends?

Can the child make himself understood by strangers?

When was the first time you noticed communication problems in your child?

What do you think could be the cause of the problem?

Do you think your child hears properly?

Child Hear explanation

Has the child had a hearing test before?

Date and Place of hearing test

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Is the child currently enrolled in any educational program?

School Name, Grade or Level

Has the child been evaluated by professionals previously?

If so, by whom, where, and when?

Is your son currently enrolled in ?

Physical Therapy
Occupational Therapy
Speech Therapy
Other

Other Program

Where are you receiving these services?

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Who does the child live with? (People who reside in the house)

Name, Relationship, Age (1 person per line)

Other immediate family members who do not live in the same house:

Name, Relationship, Age (1 person per line)

Father's occupation:

Father's Date of Birth:

Father Age

Mother's occupation:

Mother's Date of Birth

Mother's Age

Someone in your family has had

Learning disability
Allergies
Intellectual Disability
Mental Illness
Physical Disability
Speech or Language Impairments
Hearing Impairments

Which family member has suffered from allergies?

Which family member has suffered from Intellectual Disability?

Which family member has suffered from Mental Iliness?

Which family member has suffered from Physical Disability?

Which family member has suffered from speech or Language Impaiments?

Which family member has suffered from Learning Disability?

Which family member has suffered from Hearing Impairments?

How would you describe the relationships between members of your family?

What is the main language spoken in the house?

How would you describe your child?

Name of the person filling out this form

Relationship to the child:

Today's Date

Signature *

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NOTICE OF PRIVACY PRACTICES

This notice describes how medical / protected health information about you may be used and disclosed and how you can get access to this information. Please Review carefully.

Summary:

By the law, we are required to provide you with our Notice of Privacy Practices (NPP). This notice describes how your medical information may be used ad disclosed by us:

The right to inspect and copy your information;
The right to request corrections to your information;
The right to request that your information be restricted;
The right to request confidential communications;
The right to report of disclosures of your information; and
The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will ensure your information remains private.

If you have any questions about this Notice, the name and phone of the contact persons is listed on this page.

“I hereby acknowledgement that I have a copy of this practice’s NOTICE OF PRIMARY PRACTICE!”.
Understand that if I have a questions or complaints regarding my privacy rights that I may contact the person listed above. I further understand that the practice will offer me updated to this NOTICE OF PRIMARY PRACTICE should it be amended modified of change in any way “

Signature - Notice of Privacy *

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Signature

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I give Essential Therapy Services Inc permission to use or share my health information with:

The Information that will be used or shared includes: (check all that apply):

Medical Records
My treatment records (progress notes, daily records)
My speech, language, or swallowing test results
Other

Other Treatment

This Information is being used or shared because:

This authorization will expire:

If and when a patient or caregiver decides to revoke this authorization in writing.

I understand that:

I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it.
I am allowed to see or copy the health information that will be used or shared.
Any information that was used or shared before I took back the authorization cannot be returned.
The person or organization that gets my health information because of this authorization may have the right to share it with others without my permission.

Signature - Authorization for Release Information *

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Signature

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I agree to allow employees of Essential Therapy Services Inc to provide speech language pathology services for myself or my child. In addition *

I have seen and agree with the treatment goals and therapy plan
I agree to attend scheduled therapy sessions (see attendance policy)
I agree to participate in my child’s / loved one’s treatment, as appropriate.
I understand that my child / loved one bay be given work to do at home. I agree to help my child / loved one do this work to help with treatment goals.

Signature - Treatment Authorization *

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Signature

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Child's Name:

Parent's Name:

Authorized Representative's

Essential Therapy Services Inc is requesting permission to take pictures of your child. Pictures Can be used for office and/or promo􀆟onal events. Please indicate your permission by ini􀆟aling below to indicate how pictures can be used.

I am giving permission to have pictures of my child taken and to be used for office use only.
I am giving permission to have pictures of my child taken and to be used for promotional events only.
I am giving permission to have pictures of my child taken and to be used for office and promotional.
I do not want my son's picture taken for the office or other promotional events.

if you mark the last option that invalidate other options

Signature - Authorization to have picture taken *

Clear Signature

Signature

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NOTICE OF PRIVACY PRACTICES

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