Felice Center

Speech, Language, Occupational and Physical Therapy

Background Information
Questionnaire

Felice Center for Pediatric Rehabilitation
331 N. Maitland Ave., A3, Maitland, FL 32751
Tel: (321) 972-3960     Fax: (321) 972-3960     Email: office@felicecenter.com

Case History

Patient Name *
Date of Birth *
Today's Date *
Home/Cell Phone Number
Primary Care Physician
PCP Phone

Areas of Concern

Speech Therapy (ST) Please describe your concern re: your child’s speech, language or hearing.
Occupational/Physical Therapy (OT/PT) Please describe your concern re: your child’s self-help, fine motor & perceptual skills.
When did you first become aware of the difficulty?
What is the child’s reaction to his/her difficulty?

Prenatal and Birth History

Please describe the mother’s general health during pregnancy (illness, accidents, medications, etc.)
Length of pregnancy
Please describe the child’s general status or condition after birth

Medical History

Has your child ever been diagnosed with any disorder? If yes, describe
Please record any recent & past hospitalizations of your child and reasons (to include diagnosis & surgeries if applicable)
Did your child receive any immunizations? If yes, please describe
Is the child taking any medications? If yes, please list
Please describe any allergies that the child has

Developmental History

When did our child first (age in months):

Roll from back to stomach
Stand
Creep on hands and knees
Walk
Sit
Feed Self (fingers)
Use toilet (toilet trained)
Feed self (spoon)
Use single words (i.e. no, mommy, doggie, etc.)
Combine words (i.e. me go, daddy shoe, etc.)
Are there or have there ever been any feeding problems with your child (i.e. problems with sucking, swallowing, drooling, chewing)? If yes, please describe)
(ST) Does your child avoid/dislike certain food textures or types of food? Describe
(PT/OT) Do you notice any stiffness or tightness in arms or legs in your child when dressing, walking or in any other activity?
(PT/OT) Does your child fall when walking, running or turning?
(PT/OT) Does your child favor one leg or arm?
(PT) Does your child walk on tiptoes?
(PT/OT) Does your child appear uncoordinated during any activity?
Has your child had any braces, orthotics or using any assistive devices?
Has your child ever received previous occupational, physical or speech/language therapy? If yes, please describe.

Speech and Language Development

Did your child babble before speaking his/her first words?
Does (or did) your child use gestures to communicate (with speech/instead of speech)?
Is your child easily understood?
Has your child ever had his/her hearing tested? If yes, please provide most recent results of testing.
Has your child had any ear or respiratory problem? If yes, how often?
What is the child’s primary language?
What other languages does the child speak and understand?
What languages are spoken in the home?

Educational History

What is the name of the school or Daycare is your child enrolled in?
What grade is your child currently enrolled in?
Does he/she have any problems at school? If yes, please describe
Does your child receive special services? If yes, please describe

Comments

Is there any information that you would like to provide that might aid us in working with your child? Please use the space provided below for any comments and explanations
Name of person completing this form *
Relationship to Patient *
Signature *
Date *




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