History Form

Step-By-Step Therapy

History Form

Please fill out the following History Form as completely as possible.

Patient's Name
Address
Home Phone
Work Phone
Emergency Contact
Emergency Phone
Mother's Name
Mother's Occupation
Father's Name
Father's Occupation
Guardian's Name
Relationship To Child
Siblings
Insurance Company
Policy/Medicaid#
Patient's Social Security#
Patient's Date Of Birth
Doctor's Name
Doctor's Address
Doctor's Phone#
How were you referred to SBST?
Patient's Daycare/School
Does patient receive therapy through school?
Describe the mother's health during pregnancy
List any medications, illnesses, or accidents during pregnancy
Length of pregnancy?
Patient's birth weight?
Was it a normal delivery?
Was delivery Caesarian or Breech?
Was birth premature?
Patient's Medical History
Is patient allergic to latex?
List any food allergies
List other allergies
Age at which patient first sat alone?
Age at which patient first crawled?
Age at which patient first stood?
Age at which patient first walked?
Age at which patient first fed self?
Age at which hand dominance was determined?
Age at which patient was toilet trained?
Does patient have difficulty walking/running?
Does patient have difficulty writing?
Does patient have difficulty eating?
Was Patient Responsive As An Infant?
If "no," please explain.
Age of onset for First Sounds
Age of onset for First Words?
Age of onset for Phrases/Sentences?
Age of onset for Conversation?
Primary Concerns
Has patient Been tested by other specialists (psychologists, behavioral specialists, special education teachers)?
If yes, by whom?
Conculsions?
Has Patient ever had a hearing test and/or tubes?
If yes, by whom and when?
Do you feel patient has a hearing problem?
If yes, why?
How does patient get along with other children?
Does patient prefer to play alone?
What games/toys does patient prefer?
How long is patient's attention span?
Contact's email address

Step-By-Step Therapy

2760 Dora Avenue

Tavares, FL 32778

352-742-7837 Phone

352-508-5113 Fax