RED DOOR PEDIATRIC THERAPY
210 S. 12TH ST.
BISMARCK, ND 58504
PHONE: 701-222-3175
FAX: 701-222-3186

Our evaluation of your child will depend on information about his/her past history. Fill out this form as completely as possible and return to your therapist. If there are any items you do not fully understand, put a check mark in the left margin and we can discuss them when you come in for your appointment.
Today’s date: _______________________
Person completing form:______________________________Relationship to child:__________________
INDENTIFICATION:
Name:__________________________________Birthdate:_________________Sex:_______Age:______
Who does the child live with?_____________________________________________________________
_____________________________________________________________________________________
Address of child’s primary residence:_______________________________________________________
City:_______________________State:_____________Zip:______________Phone:__________________
Mother:	Father:	
Name:	Name:	
Age:                                          DOB:	Age:                                          DOB:	
Occupation:	Occupation:	
Work Phone:	Work Phone:	
Email:	Email:	

Siblings:
Name:	Age	Sex	Grade	Speech, hearing, medical problems	

					

Emergency contact (name/#):_____________________________________________________________
PHYSICIAN INFORMATION:
Referred by:____________________________________Phone Number:__________________________
Family Doctor:__________________________________Phone Number:__________________________
Affiliated Clinic:________________________________________________________________________

PREGNANCY/BIRTH HISTORY:
Which pregnancy was this child?_____________Were there any illness, diseases, or accidents that occurred during pregnancy?______________________________________________________________
_____________________________________________________________________________________
Age of mother at child’s birth:_______________Age of father at child’s birth:______________________
Length of Pregnancy:	Type of Delivery:	
Birth Weight:	Apgar Scores:	
Length of Labor:	Was labor difficult:	

Were drugs used?______________________________________________________________________
Were forceps used?_____________________________Were there any bruises, scars, or abnormalities to the child’s head?_____________________________________________________________________
Was a blood transfusion required at birth?__________________________________________________
Did the infant require oxygen?________________Was child “blue” or jaundice at birth?_____________
Were there any problems immediately following birth or during the first two weeks of the infant’s life (health, swallowing, sucking, feeding, sleeping, others)? If so, describe.___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DEVELOPMENTAL HISTORY:
At what age did your child develop the following skills:
Roll over alone:	Sat alone:	Crawled:	
Stood alone:	Walked unaided:	Fed self with spoon:	
First tooth:	Bladder trained:	Bowel trained:	
First word:	First Phrase:	Conversation:	

Hand dominance:________Has handedness ever been changed?________________________________
How does your child primarily communicate (e.g., pointing, gestures, words, phrases, sentences,       etc.)?________________________________________________________________________________
Please describe your child’s overall social behavior? My child prefers to:
Play alone:__________		Parallel play:__________	Play with others:___________
(*parallel play is to play alongside other children, but not with other children)

Communication concerns?	yes______	no______
Fine motor concerns?		yes______	no______
Gross motor concerns?		yes______	no______
Sensory concerns?		yes______	no______

MEDICAL HISTORY:
Is your child now under the care of a doctor?_________________________Why?___________________

Does your child currently carry a medical diagnosis:___________ If yes, please indicate diagnosis, medical professional who diagnosed, and date of diagnosis:____________________________________
_____________________________________________________________________________________

Is he/she taking medication?___________ Type?_____________________________________________

At what age did any of the following illness, problems, or operations occur? Indicate severity.
	Age	Mild	Mod	Severe		Age	Mild	Mod	Severe	
Adenoidectomy					High fevers					
Allergies					Influenza					
Blood disease					Mastiodectomy					
Cataracts					Measles					
Chickenpox					Meningitis					
Chronic colds					Mumps					
Convulsions					Muscle disorder					
Cross-eyed					Nerve disorder					
Croup					Orthodontia					
Dental problems					Pneumonia					
Diphtheria					Polio					
Earaches					Rheumatic fever					
Ear infections					Strep throat					
Headaches					Tonsillectomy					
Head injuries					Whooping Cough					
Hearing problems					Other:					

Allergies:_____________________________________________________________________________

What illnesses have been accompanied by an extremely long, high fever?_________________________

Temperature?_____________________ How long did the fever last?_____________________________

Has your child ever fallen or had a blow to the head?_________ If so, did he/she lose consciousness?______ Did it cause a concussion?______Did it cause nausea?_______Vomiting?_______

Did any of the above require hospitalization?________________________________________________

_____________________________________________________________________________________

Other surgeries:________________________________________________________________________

_____________________________________________________________________________________

BEHAVIOR:
Check these as they apply to your child:
	Yes	No	Explain: Give ages if possible	
Eating problems				
Sleeping  problems				
Toilet training problems				
Difficulty concentrating				
Stays with an activity				
Needs a lot of discipline				
Difficult to manage				
Underactive				
Overactive				
Laughed easily				
Cried a lot				
Sensitive				
Emotional				
Likes rough play				
Irritable				
Personality problem				
Gets along with children				
Gets along with adults				
Makes friends easily				
Has frequent tantrums				
Frequently fearful				
Gets stuck on topics				
Obsessions/compulsions				
Avoid eye contact				
Has limited interests				
Confused by gestures				
Misinterprets social situations				

Does your child separate from his/her parents without crying or fussing?__________________________

Are you concerned with your child’s behavior?________ If so, what is most concerning to you?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How do you deal with negative behaviors?__________________________________________________

_____________________________________________________________________________________

What are the child’s favorite play activities?_________________________________________________

EDUCATIONAL HISTORY:

Does your child attend daycare? _____________Where? ______________________________________

How many hours per week?______________________________________________________________

Does your child attend school?__________ Name/Address: ____________________________________

What grade is he/she in now? __________ Grades skipped: ____________ Grades failed: ____________

What are his/her average grades:_______________________ Best subjects:_______________________

Poorest subjects:_______________________________________________________________________

Is the child frequently absent from school? ________ If so, why?________________________________

How does the child feel about school or his/her teacher? ______________________________________

_____________________________________________________________________________________

Has anyone ever though he/she has learning problems? _______________________________________

Describe any speech, language, hearing, occupation/physical therapy, psychological, or special education services that your child is currently enrolled in. How often does your child attend this service?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ADDITIONAL INFORMATION:

What are your primary concerns and reasons for seeking out an evaluation: _______________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please add any additional information you feel will help us in understanding your child and his/her problems: ____________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did you hear about Red Door? ________________________________________________________

_____________________________________________________________________________________

Signature of person filling out this form: _______________________________ Date: ________________