Welcome Packet Part 1 Medical History Step 1 of 10 10% Parent or Guardian First Name:*Parent or Guardian Last Name:*Phone Number:*Email Address:* Street Address:*City:*State:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code:*Welcome! Thank you for choosing EBS Children’s Therapy of Georgia for your therapeutic needs. Our clinic has been thoughtfully planned with your child in mind. The result is a comfortable and nurturing environment where children are inspired to reach their fullest potential. Our state-of-the-art clinic boasts spacious therapy rooms and high-tech observation areas perfect for professional and family collaboration and training. That means families can observe the fun without changing the nature of the therapy session, so family members and caregivers can learn how to incorporate therapy into routines at home, ensuring more consistent carryover. Medical History - General InformationChild's Name* First Last Child's Date of Birth* Date Format: MM slash DD slash YYYY Child's GenderMaleFemaleYour Relationship to Child*ParentFoster ParentCaregiverPrimary Insurance*Insurance Provider Services Phone Number*Member ID NumberGroup NumberOther InsuranceDo you have Medicaid?*YesNoMedicaid NumberPrimary CaregiversNameRelationshipPhone Number Other CaregiversNameRelationshipPhone Number Current Concerns*Support Coordinator Name First Last Support Coordinator Phone Number Family HistoryChild lives with:*Birth ParentsOne ParentParent and Step-ParentAdoptive ParentsFoster ParentsIf divorced, is it joint custody?YesNoCan we communicate with both parents?YesNoAre we able to communicate with the step-parent?YesNoIs there anything special about the child's living situation we should know?Name and age of other children in the family:Has any immediate or extended family member experienced the following? Hearing Problems Learning Problems Cognitive Delay Seizure Disorder Congenital Disorder Autism Stuttering Please describe:What is the primary language spoken in the home?EnglishSpanishRussianChineseHindiAre any other languages spoken in the home?*YesNoList any other language(s) spoken in the child's home. Medical HistoryPREGNANCYPlease select any issues experienced by the child's birth mother. Bleeding Excessive Weight Gain Limited Weight Gain Toxemia Seizure Disorder Maternal Drug/Alcohol Use Pre-Term Labor Gestational Diabetes Infections Multiple Birth List any maternal medications.DELIVERYPlease select all that apply to the birth mother's delivery. Difficult Birth Prolonged Labor Breech Birth Brief Labor Cesarean Section Baby treated for jaundice Baby had respiratory distress Oxygen needed for baby Cord around baby’s neck Umbilical cord knot Were any of the following used during delivery? Epidural Forceps Vacuum Suction Length of Pregnancy (weeks)*Baby's Weight*Pounds (lb)Ounces (oz)Days in the hospital before discharge*Other pregnancy or delivery complicationsSelect all that apply to the child as a newborn. NICU Stay Sucking Difficulties Breathing Machine Brain Bleed Length of stay in NICU (weeks)Please indicate grade level of brain bleed.IIIIIIIVI don't know.Was the brain bleed resolved?YesNoNewborn Hearing Screening*Screened and passedScreened and failedNot screenedI don't know.Select any that apply to the child's medical history. Adenoidectomy Allergies Anxiety Asthma/Reactive Airway Disease Chronic Ear Infections Cleft Lip/Palate Depression Ear Tubes Encephalitis Failure to Thrive Head Injury Heart Problems High Fevers Lung Problems Measles Meningitis Mumps Pneumonia Scarlet Fever Seizures Surgeries Thumb/Finger Sucking Tonsillitis/Tonsillectomy Other Medical History Current Medical StatusDoes the child have allergies?*YesNoList and describe allergies.Is the child currently on any medications?*YesNoList the name, dosage, and frequency of medications.Has the child recently been hospitalized?*YesNoDate and reason for hospitalizationPrimary Care Physician*Primary Care Physician Phone Number*Primary Care Physician Office Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Select all specialists your child has seen or is currently seeing. Allergist Behavior Specialist Cardiologist Dietician Gastroenterologist Neurologist Occupational Therapist Pulmonologist Physical Therapist Psychologist/Psychiatrist Speech-Language Pathologist Does the child have a medical diagnosis?*YesNoList and describe all of the child's medical diagnoses.Are immunizations up to date?*YesNoIf not, please explain why immunizations are not up to date.*Do you have any concerns regarding the child's vision?*YesNoDoes your child wear glasses?*YesNoDate of Last Vision Screening* Date Format: MM slash DD slash YYYY Do you have any concerns regarding the child's hearing?*Date of Last Hearing Screening* Date Format: MM slash DD slash YYYY Do you have any concerns regarding the child's oral health?*YesNoDate of Last Dental Examination* Date Format: MM slash DD slash YYYY Developmental HistoryAt what age did your child do the following? Indicate “N” if they have not yet accomplished it. If you don't know exactly, just make your best estimate.COMMUNICATION Cooed/Babbled*Said first word*Followed 1-step direction*Used two words together*GROSS MOTOR Head Control*Rolled both ways*Sat on his/her own*Crawled*Walked*Jumped*Hopped on one foot*Rode a bike*FINE MOTOR Pointed with index finger*Finger fed*Ate with spoon*Cut with scissors*Drew a circle*Put on clothing*Put on shirt independently*Buttoned clothing independently*Zipped clothing independently*Toilet trained*Combed/brushed hair*Bathed independently*Tied shoes* Educational HistoryIs you child currently enrolled in preschool?*YesNoName of Child's PreschoolIs you child currently enrolled in elementary or secondary school?*YesNoWhat grade is your child in?*Name of Child's School*School District*The child is in:*General EducationResourceSelf-containedChild's Teacher's Name*Is it OK to contact the teacher?*YesNoDoes the child receive the following services in school?*Select all that apply. Speech OT PT Adaptive P.E. Social Work None of these Are there any concerns with academic skills?YesNoAre there any concerns with social skills?*YesNoHand preference:*RightLeftNot establishedDifficulty with handwriting?*YesNoNA Behavioral HistoryHas the child demonstrated or had difficulty with any of the following?Select all that apply. High Activity Level Aggresive Attention Cooperation Crying and Screaming Distraction Engaging in repetitive behaviors Excessive Movement Eye Contact Frustration Impulsiveness Loud Noises Playing with others Property Destruction Restlessness Seeking/avoiding movement Self-Abusive Behavior Separation Transitioning (to activities, places) Walking on tip-toes Willingness to try new things Withdrawal Does the child avoid certain textures/temperatures?YesNoDescribe textures and temperatures child avoids. Current CommunicationSelect all that apply to the child. Repeats sounds, words, or phrases over and over Understands what you are saying Retrieves/points to common objects upon request Follows simple directions Responds correctly to yes/no questions Responds correctly to "Wh-" questions (what, where, why, who, when) How does the child currently communicate?Looks or gestures at desired objectsMakes sounds (grunts)Words1-4 word phrasesSentencesAugmentative Communication Device Feeding DevelopmentDo you have concerns regarding the child’s feeding skills?YesNoPlease describe your concerns.Does the child have any food allergies?YesNoPlease list child's food allergies and describe reactions (if known).What foods does the child typically eat?Include type, texture, baby food, table food, etc.Where does the child usually eat?HighchairTableLapDoes the child have any history of difficulty taking the breast/bottle?YesNoIf yes, please explain.Does the child have any history of reflux or issues associated with feeding?YesNoIf yes, please explain. Family Concerns and ExpectationsWhat are some of the child’s strengths and interests?What are your concerns about the child?What do you hope to gain for the child and yourself/family from this program?Are you interested in information regarding social services (ex: psychology/family counseling, grief counseling)?YesNoIf yes, which service(s)?Has the child ever been enrolled in any of the following private therapy programs? Speech/Language Therapy Physical Therapy (PT) Occupational Therapy (OT) Psychology/Counseling/Social Work Social Skills Group Describe the child's history of speech therapy including the agency/agencies, minutes per week, date range, and approximate date of last evaluation.Describe the child's history of physical therapy including the agency/agencies, minutes per week, date range, and approximate date of last evaluation.Describe the child's history of occupational therapy including the agency/agencies, minutes per week, date range, and approximate date of last evaluation.Describe the child's history of psychology/counseling including the agency/agencies, minutes per week, date range, and approximate date of last evaluation.Describe the child's history of social skills group including the agency/agencies, minutes per week, and date range.Do you give consent for an evaluation and/or therapies to be provided by EBS Children's Therapy?YesNoDo you consent to obtain any evaluations/documentation in person per our standard method of delivery? (If not, your evaluation will be mailed to you at the address provided.)YesNoIs special training required for the provider?YesNoIs a Behavior Treatment Plan (BTP) available?YesNoReason for BTP?YesNoMethod used to gather information:
