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Schedule an ADOS

Case History

Step 1 of 11

9%

Child's Name

First Last

Date of Birth

Month

Day

Year

Address

Street Address Address Line 2 City State ZIP Code

Mother's Name

First Last

Mother's Cell Phone

Mother's Work Phone

Father's Name

First Last

Father's Cell Phone

Father's Work Phone

Does the child live with both parents?

Yes

No

If not, who has primary custody?

Mother

Father

Who is the primary caregiver?

How often does the child see the other parent?

Siblings (names and ages, do they live at home?):

List siblings here.

Pediatrician

Pediatrician Phone

Address

Street Address Address Line 2 City State ZIP Code

Neurologist/Developmental Specialist

Phone

Address

Street Address Address Line 2 City State ZIP Code

Date of diagnosis

Month

Day

Year

Please list all current known diagnoses

What primary language does your child speak?

What is the primary language spoken in the home?

Please describe your concerns for your child

Please describe your hopes/goals for your child’s intervention

When did you first become concerned about your child’s development?

Have your concerns changed since it was first noticed?

Has your child ever received ABA therapy before?

Yes

No

If yes, please indicate the name of the provider, dates of services, and hours per week

Physicians

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

Audiologists

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

Psychologists

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

Speech therapists

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

Occupational therapists

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

Physical therapist

Specialist Name

Dates of Services/Hours per week

Specialist Name

Dates of Services/Hours per week

How does the child communicate (gestures, single words, short phrases, sentences?

Does your child exhibit any problem behaviors?

Does your child have dietary restrictions?

Is your child a picky eater?

Does your child need help during meals?

Does your child have any activity, toy, show, movie or snack preferences?

Prenatal and Birth History

Mother’s general health during pregnancy (illnesses, accidents, medications, etc.

Length of pregnancy?

Length of labor?

Birth Weight

General condition

Type of delivery

headfirst

breech

Caesarian

Were there any unusual conditions that may have affected the pregnancy or birth?

Medical History

Ear infections

Yes

No

Ear infections

Past

Current

PE tubes

Yes

No

PE tubes

Past

Current

Frequent colds/sinus infections

Yes

No

Frequent colds/sinus infections

Past

Current

Bronchitis/pneumonia

Yes

No

Bronchitis/pneumonia

Past

Current

Drainage from ear

Yes

No

Drainage from ear

Past

Current

Tonsils/adenoids removed?

Yes

No

Tonsils/adenoids removed?

Past

Current

Asthma

Yes

No

Asthma

Past

Current

High fever (longer than 1 day)

Yes

No

High fever (longer than 1 day)

Past

Current

Encephalitis

Yes

No

Encephalitis

Past

Current

Seizures/Convulsions

Yes

No

Seizures/Convulsions

Past

Current

Swallowing/chewing problems

Yes

No

Swallowing/chewing problems

Past

Current

GI Issues and/or Frequent Constipation

Yes

No

Other

Please describe any major accidents, surgeries, or hospitalizations

Does your child have any gastrointestinal (GI) concerns?

Medical Testing Information

Bloodwork Specialist Name

Results found

Vision Specialist Name

Results found

Hearing Specialist Name

Results found

Genetic Specialist Name

Results found

Physicals Specialist Name

Results found

Neurologist Specialist Name

Results found

Immunizations Specialist Name

Results found

Other Specialist Name

Results found

Medication (List medications your child is currently taking.)

Name

Dose

Condition/Symptoms

Add additional medications with the plus icon.

Have there been any negative reactions to medications?

Does your child have any known allergies?

Allergy

Reaction

Developmental History

Provide the approximate age at which your child began to do the following activities

Rolled over

Crawl

Sit

Stand

Walk

Feed self

Dress self

Use toilet

Use single words

Combine words

Use simple questions

Engage in conversation

Does the child have difficulty walking, running, or participating in other activities which require large muscle coordination?

Please describe any concerns regarding your child’s fine motor skills (coloring, holding a pencil, tying shoes, zipping their jacket.

Sensory/Sensitivities: Describe any sensitivities to:

Sound

Touch

Smells

Messy activities

Crowds

Functional Skills

Mealtime

Uses bottle

Uses sippy cup

Drinks independently

Fed by others

Manages finger foods

Eats independently

Choking risks

Using utensils independently

Wanders during meals

Hygiene

Bathing assistance

Bathing independently

Dressing assistance

Dressing independently

Oral hygiene resistant

Brushing teeth independently

Toileting assistance

Toileting independently

Play Skills

issues with playing

looks at toys at eye level

lines up toys

watches wheels on toy cars

throws toys

dumps toys

repeats the play function multiple times

issues with playing, lines up toys, looks at toys at eye level, watches wheels on toy cars, throws toys, dumps toys, repeats the play function multiple times

Can he/she

Tie shoes

Buttons

Zipper

None

Educational History

School

Grade

Teacher

Days/times in school

How is your child doing academically?

Does your child have a current Individualized Education Plan (IEP)?

Yes

No

Primary classification

Classroom setting

General Education

Resource

Self-Contained

Does your child receive special services in school?

Speech

OT

PT

None

If yes, how many hours per week?

How does the child interact with peers? (shy, aggressive, uncooperative, observant)

Miscellaneous

Place a checkmark next to any items that are difficult for your child

Eating a variety of foods

Following directions

Following routines

Communicating what he/she wants

Stating sounds of letters

Writing his/her name

Rhyming

Understanding concept of time

Telling stories

Self-calming

Speaking in grammatically correct sentences

Receiving/giving hugs

Keeping shoes on

Eye-hand coordination

Using a straw

Keeping hands to him/herself

Reading

Having a conversation

Listening to other people speak

Playing with peers

Answering question

Public Places

Please check all that describe your child

Friendly

Impulsive/impatient

Separation difficulties

Easy-going

Poor eye contact

Plays well with other children

Hyperactive

Cooperative

Aggressive/destructive

Doesn't like to be read to

Attentive

Has temper tantrums

Poor memory

Willing to try new activities

Unpredictable

Sleeps well

Defiant

Will not eat certain textures

Eats well

Cannot easily shift between activities

Will not touch certain textures

Plays alone for long periods of time

Bites nails

Overly sensitive emotionally

Doesn't like to be touched

Stubborn

Still uses pacifier/sucks thumb

And More...

Talkative

Bad-tempered

Has nightmares

Clumsy

Cries easily

Grind’s teeth

Distractible/short attention span

Wet’s bed

Easily frustrated

Withdrawn

Mouth breather

Restless

Shy

Snores

Quiet

Daydreams often

Sensitive to sound

Provide any additional information that might be helpful in evaluating/treating your child

Name of person completing form

First Last

Date

Month

Day

Year

Relationship to client

Signature

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

Δ

Contact Us

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Phone: 239-349-3139
Fax: 239-984-4372
[email protected]

12501 World Plaza Lane, Building 51
Fort Myers, FL, 33907

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