Travis
Pediatric Therapy Center
160 Dowlen
Beaumont, TX 77706
Phone 409.861.1000
Fax 409.861.2241
Pediatric Outpatient Clinic
Physical Therapy Case History Form
Child’s Name:
Date:
Birthdate:
Gender:
Age:
Height:
 Male
 Female
Pediatrician’s Name:
Phone:
Child lives with (check one):
Birth parents
Foster parents
One Parent
Adoptive Parents
Please list other children in the family:
Name
Age
Child’s race/Ethnic Group:
 Caucasian, Non-Hispanic
 Hispanic
 African-America
Parents and Step Parent
Other
Sex
Grade
Speech/Hearing Problems
 Native American
 Asian or Pacific islander
 Other
Is there a language other than English spoken in the home?
If yes, which one?
Does the child speak the language?
Does the child understand the language?
Who speaks the language?
Which language does the child prefer to speak at home?
Birth History
Pregnancy/Delivery
Pregnancy Proceeded
Weight:
 Yes
 No
 Yes
 Yes
 No
 No
 Without Complications
 With Complications
 Pre-Eclampsia
 Gestational Diabetes
 Multiple Births
 Other:
Length of Pregnancy (in weeks)
Mother’s age at time of birth
 Eclampsia
 Premature Labor
Prenatal care  Received  Not Received
Birth Hospital
Delivery Proceeded
 Without Complications
 With Complications
 Abruptio Placenta
 Prolapsed Cord
 Breech Presentation
 Transverse Presentation  Negative Vacuum
 Use of Forceps
 Placenta Previa
 Uterine Rupture
 Low Amniotic Fluid
 Premature Rupture of Placenta
 Umbilical Cord Wrapped Around Neck
 Other
Delivery was  Vaginal
 C-section  Emergency C-section
Days in Hospital
Birth Weight
Birth Height
Apgar Scores @
1 min
5 min
10 min
Comments
Following Birth
Complications Following Birth
 Anemia of Prematurity
 IVH Bleed Grade II
 Brachial Plexus Injury
 Congenital Heart Disease  IVH Bleed Grade III
 Maconium Aspiration
 Metabolic Acidosis
 IVH Bleed Grade IV
 Cleft Lip
 Cleft Palate
 Bronchopulmonary Dysplasia
 Club Foot
 Failure to Thrive
 Respiratory Distress Syndrome
 Congenital Hip Dislocation  Ventilator Dependency
 Retinopathy of Prematurity ‘ROP’
 Tube Fed  Other
Diagnosed or Suspected Syndromes/ Medical Diagnoses/ Orthopedic Conditions:
Health Issues
Has your child had any of the following?
Adenoidectomy
Ear tubes
Allergies
Encephalitis
Breathing difficulties
Flu
Broken bones
Head injury
Which ones?__________
High fevers
Chicken pox
Measles
Colds
Meningitis
 Colic
 Metabolic Disorder
 Constipation/Diarrhea
 Mitochondrial Disorder
Ear infections
Mumps
How often?___________
 Reflux
Scarlet fever
Seizures
Sinusitis
Sleeping difficulties
Thumb/finger sucking habit
Tonsillectomy
Tonsillitis
 Tube Feeding
Vision problems
Current Medications
Hearing Test
Test Date
 Never Tested, No Concerns
 Never Tested, Have Concerns
 Normal Test Results
 Abnormal Test Results
Results
Vision Test
Test Date
 Never Tested, No Concerns
 Never Tested, Have Concerns
 Normal Test Results
 Abnormal Test Results
Results
Specialists Seen
Specialist
Allergist
Audiologist
Cardiologist
Developmental Medicine
Endocrinologist
ENT
Gastroenterologist
General Surgeon
Geneticist
Hand Surgeon
Nephrologist
Neuro-Surgeon
Neurologist
Oncologist
Opthamologist
Orthopedic
Orthotist/Prosthetist
Pediatrician
Physiatrist
Physical Medicine & Rehab
Podiatrist
Psychiatrist
Pulmonologist
Urologist
Test
X-ray
CT Scan
MRI
MBS (Swallow Study)
Type
Name
When
When
Reason for Visit
Diagnostic Tests
Results
Surgeries & Procedures
Age
Results
 None
 Deep Brain Stimulator
 Osteoporosis
 Seizure Disorder
Contraindications/Precautions
 Allergies
 Baclofen Pump
 Braces
 Shunts
 Tube Feeding
 Vagal Nerve Stimulator
Developmental History
Milestone
Grabs Toys
Holds Head Up Alone
Rolls Over
Sits Alone Without Support
Crawls Alone
Creeps Alone
Motor/ Sensory Development
When (in months)
Milestone
Pulls to Standing Position
Walks Independently
Climbed (stairs/onto furniture)
Jumps
Fed him/herself finger foods
Toilet Trained
When (in months)
Describe how your child gets around the house:
Favorite Toys/Play Activities:
Which hand does your child prefer?
Does your child…
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Right
 Left
 Neither
Fall or lose his/her balance easily?
Visually look at people and/or toys?
Show a negative response when touched or when touching other objects?
Enjoy movement such as swinging or roughhousing?
Play and/or participate in leisure activities daily?
Get involved in community programs (school, special rec, scouts, etc.)?
Milestone
Began Eating Baby Food
Began Eating Junior Food
Began Eating Table Food
Began Using a Cup, Sippy Cup, Straw
Feeding / Speech / Language
When
Milestone
(in months)
Babbling
First Word(s)
Two Word Combinations
Completed Sentences
Participated in Conversation
Describe any feeding problems:
Food Likes/Dislikes:
Primary Communication
 Verbal
 Vocalizations
 Single Words
 Phrases
 Sentences
 Non-Verbal
 Body Language
Communication Device
 Eye Gaze  Facial Expressions
 Pointing/Gesturing  Sign Language
When
(in months)
Behavioral Characteristic
Please check all that apply
 Cooperative
 Attentive
 Willing to try new activities
 Plays alone for reasonable length of time
 Separation difficulties
 Easily frustrated/impulsive
 Stubborn
 Restless
 Poor eye contact
 Easily distracted/short attention
 Destructive/aggressive
 Withdrawn
 Inappropriate behavior
 Self-abusive behavior
School History
Grade in School
Name of School
Does your child have an IEP from school?  Yes  No
Therapy Services
Aquatic Therapy
Assistive Technology
Audiology
Behavior Therapy
Hippotherapy
Nutrition
Occupational Therapy
Physical Therapy
Speech Therapy
Vision Therapy
Please return to:
Status
Where
S.T.A.R.S. Pediatric Outpatient Clinic
160 Dowlen Road
Beaumont, Texas 77706
Frequency/Duration
OR
Fax to:
409-861-2241