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Therapy Evaluation Form

Today's Date is:

Child's Name:

Parent's Name:

Address:

City:

State:

Zipcode:

Home Phone Number:

Cell Phone Number Optional:

Work Number:

Referred By:



Reason for Referral:

Email Address:

Born at ( # of week's gestation ):

Bith Weight:

Characteristics of pregnancy and delivery:

Diagnosis:

When diagnosed:

Diagnosed by whom:

Pediatrician name/ contact information:

Other specialists / therapists involved in child’s care:

Other examinations / results
(e.g. vision, hearing):

Allergies:

Medications:

Seizures:

Feeding history:

Sleep history:

Recent illnesses/Hospitalizations:

General health:

Parents’ occupations:

Siblings’ names/ages:

Family illnesses/conditions:

Recent family changes/significant events/trauma:

Childcare/babysitters:

Fine motor
(reaching, grasping, handedness, use of crayons, scissors, pencils, utensils, etc.):

Self-help skills
(feeding, dressing, hygiene):

Communication skills (verbal/non verbal, use of language):

School/childcare/grade:

Teacher’s observations of behaviors/skills:

Extracurricular/community activities:

General activity level (highly active, active, sedentary):

Unusual behaviors (hand flapping, tantrums, repetitive play):

Behavior management (how to calm child, rewards, incentives, etc.):

Favorite activities/toys:

Play/socialization with others (adults, peers, siblings):

Sensory History (reactions to touch, sounds, movement):

Current description of fine motor, gross motor, self-help skills:

Special diets, precautions