PARENTS’ CONFIDENTIAL REPORT All the following information is for the confidential use of Professional staff only. According to my records, you have requested an examination for your child. In preparation for this examination, I would like you to provide me with the requested information of this form. This information is very important and will assist me in planning for and conducting a meaningful examination. Please answer the questions as fully and accurately as possible. Many parents have found the child’s baby book helpful in remembering particular dates. If you are not sure of a particular date, please write the date that you think is right and put a question mark after it. Date:______________ Child’s name:_____________________________________Birthdate:_____________Sex:_________ (first) (last) Street Address:__________________________________________Telephone:____________________ City:_______________________State:______County_______________________Zip______________ Child’s Physician_____________________Complete address:___________________________________ Referred by:________________________________________________________________________ Presenting Concerns:__________________________________________________________________ Parents: Marital Status of Parents: Married______Separated______ Divorced______Widowed_____Single__________ FATHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age____________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ MOTHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age:___________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ Describe in your own words your concerns :___________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
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PARENTS’ CONFIDENTIAL REPORT · PARENTS’ CONFIDENTIAL REPORT All the following information is for the confidential use of Professional staff only. According to my records, you
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PARENTS’ CONFIDENTIAL REPORT All the following information is for the confidential use of Professional staff only. According to my records, you have requested an examination for your child. In preparation for this examination, I would like you to provide me with the requested information of this form. This information is very important and will assist me in planning for and conducting a meaningful examination. Please answer the questions as fully and accurately as possible. Many parents have found the child’s baby book helpful in remembering particular dates. If you are not sure of a particular date, please write the date that you think is right and put a question mark after it. Date:______________ Child’s name:_____________________________________Birthdate:_____________Sex:_________ (first) (last) Street Address:__________________________________________Telephone:____________________ City:_______________________State:______County_______________________Zip______________ Child’s Physician_____________________Complete address:___________________________________ Referred by:________________________________________________________________________ Presenting Concerns:__________________________________________________________________ Parents: Marital Status of Parents: Married______Separated______ Divorced______Widowed_____Single__________ FATHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age____________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ MOTHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age:___________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ Describe in your own words your concerns :___________________________________________________
CHILDREN (use additional page if necessary) Name Sex Birthdate Age Special Problems ____________________ ________ ___________ ____ ______________________ ____________________ ________ ___________ ____ ______________________ ____________________ ________ ___________ ____ ______________________
BIRTH HISTORY:
Normal Pregnancy?______________ Complications during pregnancy?___________________________
Any special tests during pregnancy?_____________________________________________________
Diet or medications?_________________________________ Weight gained?____________________
How long was labor?______________________ Was your child pre-mature?________________________
Any difficulties during delivery?________________________________________________________
Delivery by C-Section or vaginal? _______________
Did baby have any special problems or birth defects?__________________________________________
Approximate birth weight:__________________ Length of baby:_______________________________
DEVELOPMENTAL HISTORY (Give the age when your child:)
Sat alone: ____________Walked alone:____________ Crawled on hands and knees: _________________
Said first word:___________ Fed self:__________
Said first sentences:_______________ Toliet trained for day:______________ Night:________________
What are your child’s strengths and/or best subjects? __________________________________________
___________________________________________________________________________________ Has your child ever had an IEP? __________ Where?____________________ When? ______________
3 BEHAVIORAL CHARACTERISTICS Please circle all traits which best characterize your child’s current behavioral characteristics: cooperative poor eye contact attentive easily distracted withdrawn separation difficulties destructive/aggressive inappropriate behavior easily frustrated/impulsive plays alone for reasonable
length of time hyperactive
MEDICAL HISTORY Has your child experienced any of the following? (Please circle all that apply and list child’s age at time) adenoidectomy encephalitis seizures allergies flu sinusitis chicken pox head injury sleeping difficulties frequent colds measles meningitis tonsillectomy mumps scarlet fever vision problems earaches or draining in ears hearing problems vomiting headaches serious high fevers diminished sleep Has your child had Convulsions, spasms or seizures?_____ How many?_____ When was the last?_______________
Clumsiness or weakness of arms or legs?________________________________________________________
Does your child wear glasses?______ Date of last eye exam? _________________________________________
Bedwetting?______ Excessive number of accidents?_______________________________________________
Has your child received medical attention for hearing problems? _____ When? ______________________
-Verbal instructions with gestures_____ Gestures alone_____
How does your child make his needs known to you?___________________________________________
Has your child received services of any of the following: If yes, please give name, address and date seen. Also, please
contact those people/agencies below and have them send a copy of their findings to: Word of Mouth Speech & Learning
Associates, 217 Jamestown Park Road – Suite 9, Brentwood, TN 37027.
Psychologist:_____________________________________________________________________ Psychiatrist______________________________________________________________________ Pediatrician/Family Dr.:_____________________________________________________________ Otolaryngologist:__________________________________________________________________ Neurologist:_____________________________________________________________________ Other doctors:____________________________________________________________________ Speech Therapist:__________________________________________________________________ Speech and Hearing Center:___________________________________________________________
5 Physical Therapy: __________________________________________________________________ Occupational Therapy: ______________________________________________________________ Social Agency or Worker:____________________________________________________________ State or County Welfare Dept._________________________________________________________ Any testing by local school system:______________________________________________________ Guidance or Mental Health Center:______________________________________________________ County Health Dept.:_______________________________________________________________ Other agencies:___________________________________________________________________ Have you thought about or made application for other services at other agencies for your child?____________
ADDITIONAL COMMENTS AND OTHER IMPORTANT INFORMATION: If your child is adopted, please give any information you may have pertaining to natural parents:_______________
Name of person who completed this form and relationship to child:________________________________
______________________________________________________________________________ Signature:_______________________________________________________________________ (Father) (Mother) (Guardian) (To be signed by both parents if living together)
Name of Student: _______________________________________________ Age: ____ Date of Birth: _____________ School: __________________________ ________________________ School Phone: _________________ Grade: ____ Teacher(s):___________________________________________________________________________________________ Teacher(s) e-mail:______________________________________________________________________________________ Allergies: ____________________________________________________________________________________________ Pediatrician: __________________________________________________________________________________________
Mother: _____________________________________ Phone: (home) ________________ (cell)________________ Employer: ___________________________________ Phone: (work) ________________ Home Address: _____________________________ City: _______________ Zip : ______ Email Address: _______________________________________________________ Father: _____________________________________ Phone: (home) ________________ (cell)_______________ Employer: ____________________________________ Phone: (work) _______________ Home Address: _____________________________ City: _______________ Zip : _____ Email Address _______________________________________________________ Do you mind if your child’s session is briefly discussed with you in our lobby (with the therapist bringing you back to a therapy room for more sensitive discussions)? Check: Yes, I do mind _______ No, I do not mind ________ May Word of Mouth Speech & Learning Associates and Eppert OT display a picture of your child for use in Word of Mouth publications such as brochures or website? Check: Yes ________ No ________
The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the "medical records privacy law", HIPAA provides patient protections related to the electronic transmission of data ("the transaction rules"), the keeping and use of patient records ("privacy rules"), and storage and access to health care records ("the security rules"). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. This “Patient Notification of Privacy Rights” informs you of your rights related to disclosure of information. If you have questions about any of the matters discussed in this document, please ask your provider or Lynne F. Robertson, M.A., CCC – SLP (HIPAA contact for this office) for further clarification.
I, _________________________________, understand and have been provided a copy of Word of Mouth Speech & Learning Associates Patient Notification of Privacy Rights Document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form. Parent Signature: ___________________________________