Baylor Autism Resource Clinic (BARC)
Baylor University Center for Developmental Disabilities
Case History Form
This information is strictly confidential and cannot be provided to individuals or agencies
without written consent.
CHILD HISTORY
Date: _______________
Identifying Information
Child’s Name: ____________________________________________________________
Age: ________ DOB: ____________ Sex: Male Female Current grade in school: ______
Home Street Address: _________________________________ City: ______________________
State: _________________ Zip code:_____________
Mother’s Name: _______________________________ Age: _______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:________________ Cell phone:
______________
Occupation: _________________________ Email: _______________________
Father’s Name: _________________________________ Age: ______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:________________ Cell phone:
______________
Occupation: _________________________ Email: ___________________________
Guardian’s Name: _______________________________ Age: _______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:___________________
Cell phone: ___________________ Occupation: _________________________
Home Language ____________________ Other languages spoken in the home ___________
Have you been seen at this facility previously? _________ Date/s: __________________
Does your child have hearing problems? Y N If yes, what is being done?
____________________________________________________________________________________
____________________________________________________________________________________
Does your child have vision difficulties? Y N If yes, what is being done?
____________________________________________________________________________________
____________________________________________________________________________________
I. Statement of Problem/ Referral:
MUST ANSWER THESE QUESTIONS
Describe as completely as possible the speech, language, hearing, and/or behavioral problem.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Referral Source:
_______________________________________________________________________
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When was the problem first noticed?
____________________________________________________________________________________
____________________________________________________________________________________
How has the problem changed since you first noticed it?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What has been done about it? Has this helped?
____________________________________________________________________________________
____________________________________________________________________________________
What do you hope to learn from this evaluation and what do you think should be done?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Tell us more about previous evaluations or services provided with approximate dates:
Speech therapy: ______________
Physical therapy: ____________________
Occupational therapy: __________
Cook’s Children’s Hospital, Dallas
Scottish Rite Hospital, Dallas
Callier Center, Dallas
Klaras Center, Waco
MHMR, Waco/other
Child Protective Services
Counseling services
Psychological services
Public school
Audiology
Other
List diagnosis/es: ____________________________________________________________
Describe services: __________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Family
Other Children (including step-siblings and half-siblings, foster, adopted) :
Name
Age
Sex In Home:
School/behavioral/health Problems
Is the child adopted? ______________________ Age adopted _________________
If adopted, describe the child’s relationship with the parents and/or guardian(s) Does the child have
contact with his/her biological parents?:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Others living in the home:
Name
Age
Sex
Relationship School/behavioral/health Problems
Birth Mother
Birth Father
Describe any learning difficulty:
__________________________________
________________________________
Describe any behavioral problems of either parent and treatment provided:
__________________________________
________________________________
__________________________________
________________________________
__________________________________
________________________________
Describe any psychological or psychiatric problems of parent(s) for which treatment was received:
__________________________________
________________________________
__________________________________
________________________________
__________________________________
________________________________
Any parental history of Attention-Deficit/Hyperactivity Disorder? Describe treatment if any:
__________________________________
________________________________
__________________________________
________________________________
__________________________________
________________________________
This information is important for diagnosis and treatment. Please answer carefully and
specifically.
Histories
Prenatal and Birth History
A. Pregnancy
Length in months ________
Normal Birth _____
If problems existed, please check those that apply and specify trimester:
Excessive bleeding
German measles
Mother – bed rest
High blood pressure
Diabetes
Smoking
Previous miscarriage
RH incompatibility
Brain injury
Toxemia
X-ray treatment
Serious accident
Premature membrane/
Mother- alcohol use /
Mother – drug
Rupture
abuse
use / abuse
Comments or other illnesses/complications: __________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
Please list any medications taken during pregnancy: ____________________________________
______________________________________________________________________________
Was the father taking any medication or drugs at the time of conception? If so, please specify: __
______________________________________________________________________________
B. Birth
Normal Birth _____ APGAR Score: _____
Length of labor _______ Birth weight ______ Birth length _____
If problems existed, please check those that apply:
Vaginal birth
C-Section
Breach
Breathing problems
Jaundice
Extended hospital stay
Incubator
Cyanosis
Seizures
Injury
Deformity
Infection
Anoxia
Difficult delivery
Feeding difficulty
Cleft/ lip palate
Swallowing/sucking
Physical Abnormalities
problems
Specify _____________
Explain any complication related to birth _____________________________________________
______________________________________________________________________________
Infancy and Early Childhood
Please rate your child on the following behaviors: Circle 1 if the behavior on the left was
present the majority of the time. Circle 5 if the behavior on the right was present most of
the time. Stages in between are represented by 2, 3, and 4.
Quiet and content 1
Very easy to feed
1
Slept well
1
Usually relaxed
1
Underactive
1
Cuddly, easy to hold 1
Easily calmed down 1
Cautious and careful 1
Coordinated
1
Enjoyed eye contact 1
Liked people
1
2
2
2
3
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
colicky and irritable
daily feeding problems
frequent sleeping problems
often restless
overactive
did not enjoy cuddling
tantrums, headbanging
accident prone, daredevil
uncoordinated
avoided eye contact
disliked people
Other problems or comments regarding infancy or early childhood development: ________
______________________________________________________________________________
______________________________________________________________________________
Did any event, health condition, separation, etc., disturb early infant/mother bonding or the
developing toddler/mother relationship? If yes, please explain: ________________________
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______________________________________________________________________________
______________________________________________________________________________
III. Child Development
Your general impression of the child’s overall development:
slow _____
normal_____
advanced_____
A. Motor development
slow _____
normal ____
advanced ____
Give ages at Milestones:
Sat alone
Crawled
Reach and grasp
Walked
Potty trained (day)
Fed self
Ran well
Potty trained (night)
Dressed self
Scribbled
Tied shoes
Explain/note any motor difficulties: __________________________________________________
________________________________________________________________________________
________________________________________________________________________________
B. Speech and Language Development
Can you understand your child’s speech?
______________________________________________________________________________
Do others who have difficulty understanding your child’s speech?
______________________________________________________________________________
Is your child aware of the problem? Explain
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Tell your child’s reaction to his own speech difficulties
______________________________________________________________________________
Tell the reaction of you and other family members to the
problem_______________________________________________________________________
______________________________________________________________________________
Family history of speech/language problems
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What do you do to help your child?
______________________________________________________________________________
______________________________________________________________________________
If your child has difficulty producing sounds, which ones are problems?
____________________________________________________________________________________
________________________________________________________________________
Does your child understand words spoken to him/her?
____________________________________________________________________________________
________________________________________________________________________
Does he/she understand conversation? ______________________________________________
Does your child repeat words or show difficulty with breaks in his speech?
______________________________________________________________________________
5
______________________________________________________________________________
Does your child stutter: none _____ rarely _____ occasionally _____ frequently _____
If yes, then how long has this been a problem?
_______________________________________________
Does your child have an unusual voice quality? (loud, soft, hoarse, nasal)
______________________________________________________________________________
Give other information to explain your child’s communication problem
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Fill in age that behaviors began:
Cooing sounds
Vocal play/babbling
First words
Phrases
Short sentences
Tell the way your child lets you know what he/she wants at this time
Eye gaze
Pointing
Gestures
Moves other’s hand/body
Single words
2-3 word phrases
Crying
Vocalizing
Complex sentences
Signs / augmentative
C. Behavioral and Mental Health History
Check if they apply:
Behavior
Home
School
Other
Compliant behavior
Learning problems
High activity level for age
Difficulty following directions
Difficulty maintaining attention
Impulsivity (not thinking before acting)
Difficulty playing with others
Prefers to play by him/herself
Difficulty getting along with peers
Problems with adult authority
Aggressive
Behavior problems
Friendly, outgoing
Shy
Easily distracted by:
Overly sensitive to stimuli
Low response to stimuli
Please describe any behaviors of your child at home that are particularly concerning you or other
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family members:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please describe any behavior of your child at school that is of particular concern:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Does your child seem to be able to control his/her behavior?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Toys or activities the child prefers to play with:
______________________________________________________________________________
______________________________________________________________________________
Describe any discipline difficulties:
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
How do you discipline at home and how frequently do you have to discipline?
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
How does your child respond to discipline? ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Does your child exhibit any strange behaviors using the five senses (touch, taste, smell, sight,
hear)? If so, please explain:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Does your child have any major dislikes or unusual fears? If so, please explain:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Describe any special skills or areas of particular interest your child has:
______________________________________________________________________________
__________________________________________________________________
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Describe your child’s established routines at home:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Describe your child’s eating and sleeping habits:
______________________________________________________________________________
__________________________________________________________________
How does your child react to pain?
______________________________________________________________________________
__________________________________________________________________
Explain current significant family stresses
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Previous family stressors or events that you think may have had an impact on his/her development and
current functioning: ___________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________
Has your child ever been subject to abuse (physical, sexual, emotional)? _____________________
If so, what type and when? Did your child receive any treatment?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Describe your child’s relationships with others his or her age throughout his/her development:
____________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Has your child or family received any professional mental health treatment, such as individual or
family counseling, group counseling, etc.? Yes
No
Please list any past and current treatments, including length of treatment: ___________________
______________________________________________________________________________
__________________________________________________________________
Do you feel the treatment is/was helping or effective? Please explain:
______________________________________________________________________________
______________________________________________________________________________
Present personality and behavior.
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Please describe your child’s personality characteristics (friendly, outgoing, independent,
affectionate, cooperative, moody, etc).
______________________________________________________________________________
__________________________________________________________________
Have you noticed any recent changes in your child’s behavior?
______________________________________________________________________________
__________________________________________________________________
Describe your child’s interactions with others in the neighborhood, community, or other leisure
activities outside the home:
______________________________________________________________________________
__________________________________________________________________
IV. Medical History
Illnesses/Conditions
Check those that apply and fill in approximate date/s:
Allergies
Hearing aids- which ear R L
Amputations
Hearing amplification device
Asthma
Hearing problems
Attention Deficit Disorder
High fevers
Augmentative communication device
Hoarseness
Autism
Lengthy medication treatment
Auto accidents
Measles
Behavior problems
MR
Braces
Nightmares
Brain injury
Obturator
Cerebral palsy
Other surgery:
Chickenpox
Hospitalization for ________________
Cleft palate/submucous cleft
Pervasive Developmental Disorder
Cochlear implant
Physical Abnormalities
Convulsions
Poor appetite
Digestive problems
Schizophrenia
Down’s Syndrome
School phobia
Drooling
Seizures
Dyslexia
Sensory integration disorder
Ear infections
Serious injury:
Emotional problems
Stuttering
Encephalitis
Swallowing problems
Falls frequently/balance
Syndrome (other): ________________
Feeding/eating problems
Thumbsucking
Fragile X Chromosome Disorder
Tongue-tie
Frequent colds
Tonsillectomy and/or Adenoidectomy
Glasses
Tubes in ears
Hand preference R L
Vision problems
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Head injury
Vocal nodules
Is the child currently under a doctor’s care? Give diagnosis and physician’s names:
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Doctor’s place of business and phone number:
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
What current medication is he/she taking?
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Has your child been to the emergency room with a serious emergency, hospitalized, or had
outpatient surgery since birth? If yes, please describe incidents along with date, duration, and
where he/she was seen:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
V. School History
Schools attended:
School/
Grade
Name of
Academic
Academic
Dates
Level
School
Strengths
Weaknesses
Day care/Nursery
Preschool
PPCD
Kindergarten
Elementary
Middle School
High School
Private
Homeschooled
Has your child been held back or repeated a grade? Y N
Explain
______________________________________________________________________________
__________________________________________________________________
Currently, what are your child’s grades?
______________________________________________________________________________
__________________________________________________________________
Has your child been tested at school to address developmental, learning, or speech-language difficulties?
Y N
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If yes, explain Results:
______________________________________________________________________________
__________________________________________________________________
What special education services has your child received for difficulties in school? (check all that apply)
Speech therapy ___
resource ___
self contained ____
OT ____
Other: ____
What modifications have been used in school to support your child?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
How does he/she feel about school?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
How did your child adjust to the school environment when he/she began school/daycare?
______________________________________________________________________________
__________________________________________________________________
Does your child learn easier with a particular style of learning? Explain:
Auditory ________________________________________________________________
Visual ________________________________________________________________
Both
_________________________________________________________________
Other activities your child is involved in outside of school (sports, lessons, church, tutoring, Scouts,
etc.):
______________________________________________________________________________
______________________________________________________________________________
Please give any additional information that will help us in evaluating your child:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Child’s primary physician
Name_____________________________________
Address _____________________________________________________
Phone Number_______________________________
Diagnosis ____________________________________________________
Other professionals who have treated/evaluated the child
Name/Position_________________________________________________
Address______________________________________________________
Phone Number_______________________________
Diagnosis ____________________________________________________
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I wish reports to be sent to these persons/agencies:
Name _______________________________________________________
Title _______________________________________________________
Address _____________________________________________________
Phone ________________________
Name _______________________________________________________
Title _______________________________________________________
Address _____________________________________________________
Phone ________________________
___________________________________
Signature of person completing this form
__________________
Relationship to child
____________
Date
Applications may be submitted by email, fax, or mail.
Baylor University Center for Developmental Disabilities
2201 MacArthur Drive, Suite 101
Waco, TX 76708
bcdd@baylor.edu
Phone: 254-537-1042
Fax: (254)-224-6633
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Baylor University Center for Developmental Disabilities (BCDD)
Consent to Request Confidential Information
Client name: __________________________________Date of birth: _______________
To Whom It May Concern:
I hereby grant permission for_______________________________________________
(name of school/institution)
To disclose and deliver any information requested by Baylor Center for Developmental Disabilities.
concerning my son/daughter ________________________________________________.
This may include verbal or written information regarding case history, results of
examination, impressions, and recommendations that might benefit Baylor Center for Developmental
Disabilities in treating the client.
Yes
No
(name of school/institution/above agency)
I have been fully informed and understand the center’s request
for my consent, as described above. This information will be
released/requested upon receipt of my written consent.
Yes
No
I understand that my consent is voluntary and may be revoked
at any time, except where information has already been released.
Yes
No
I understand that Baylor University, its employees, and officers
are released from any legal responsibility or liability for disclosure of the above
information to the extent indicated and authorized herein.
Signature:____________________________________________
Relationship:_________________________________________
Date:__________________________________________________
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