Child's/Patient's Full Name
*
First Name
Last Name
Mother's Full Name
*
First Name
Last Name
Father's Full Name
*
First Name
Last Name
Mother's Email Address
*
Father's Email Address
*
Mother's Cell Phone Number
*
Father's Cell Phone Number
Patient's Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient's Mailing Address
If the same as home address, please leave blank.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child Lives With
*
Both Parents
One Birth Parent and One Step Parent
Grandparent(s)
Relative(s)
Other
Mother's Occupation
*
Father's Occupation
*
Names & Ages of Siblings Living at Home
*
Languages Spoken at Home
*
English
Spanish
English and Spanish
Other
How Did You Hear About Us?
*
Friend
Physician
Online Search
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Other
Primary Care Physician
*
First Name
Last Name
Other Physicians Your Child Has Seen in the Last 3 Years
*
Please list the physician(s) name and specialty.
Referring Physician
*
First Name
Last Name
Medical Diagnosis (if known)
*
Medical Precautions We Should Be Aware Of
*
Previous Notable Illnesses or Injuries
*
If any, please include dates of duration.
Child's Current Medications
*
Please include name of medication, dosage and frequency.
Child's Current Allergies
*
Does Your Child Wear Prescribed Corrective Lenses?
*
Describe Pregnancy
*
Problems During Pregnancy?
*
Please explain.
Procedures and/or Medications Required for Mother at Birth?
*
Please explain.
Type of Delivery
*
Head First Spontaneous
Head First Induced
Feet First
Forceps
Vacuum Assist
Planned Cesarean Section
Unplanned Cesarean Section
Child's Gestational Weeks at Birth
*
Child's Birth Weight
*
Child's Current School Level
*
Not Yet School-Age
Pre-School
Grade School
Middle School
High School
School District
Has Child Previously or Currently Attended PPCD?
*
Has Child Attended Any Other Schools Previously?
Please list any other schools your child has attended.
Does Your Child Have Challenges in School?
*
If Yes, Please Explain
Does Your Child Get Along Most of the Time With Family Members?
*
If No, Please Explain
Does Your Child Adapt Easily To Changes in His/Her Routine?
*
Does Your Child Play Regularly With At Least One Friend in His/Her Age Group?
*
My Child Tends to Be A:
*
Does Your Child Have Behavioral Trouble?
*
Child's Social Behavior Compared to Same Aged Peers Is:
*
How Do You Discipline Your Child?
*
Important Remarks Related to Your Child's Social History:
*
Why Are You Seeking Therapy for Your Child?
*
What Are the Main Goals You Wish Your Child to Achieve in Therapy?
*
Did Your Child Do These Things at An Appropriate Age Level?
Please Answer All That Apply for Your Child, Per His/Her Current Age.
Held Up Head
Sat Unsupported
Crawled
Pull to Stand
Sat Alone
Walk Alone
Toilet Trained
Dress Self
Feed Self with Spoon
Feed Self with Fork
Drink From a Straw
Drink From a Cup
Name Things
Play With Sounds
Use Jargon
Use Clear Sounds
Use Short Sentences
Babble
