Baylor Autism Resource Clinic (BARC)Baylor University Center for Developmental Disabilities

Case History FormThis information is strictly confidential and cannot be provided to individuals or agencies

without written consent.CHILD HISTORY

Date: _______________Identifying InformationChild’s Name: ____________________________________________________________Age: ________ DOB: ____________ Sex: Male Female Current grade in school: ______Home Street Address: _________________________________ City: ______________________State: _________________ Zip code:_____________Mother’s Name: _______________________________ Age: _______________Address:__________________________________________________________Home phone: ______________________ Work phone:________________ Cell phone: ______________Occupation: _________________________ Email: _______________________Father’s Name: _________________________________ Age: ______________Address:__________________________________________________________Home phone: ______________________ Work phone:________________ Cell phone: ______________Occupation: _________________________ Email: ___________________________Guardian’s Name: _______________________________ Age: _______________Address:__________________________________________________________Home phone: ______________________ Work phone:___________________Cell phone: ___________________ Occupation: _________________________

Home Language ____________________ Other languages spoken in the home ___________Have you been seen at this facility previously? _________ Date/s: __________________

Does your child have hearing problems? Y N If yes, what is being done? ________________________________________________________________________________________________________________________________________________________________________Does your child have vision difficulties? Y N If yes, what is being done? ________________________________________________________________________________________________________________________________________________________________________

I. Statement of Problem/ Referral: MUST ANSWER THESE QUESTIONSDescribe as completely as possible the speech, language, hearing, and/or behavioral problem. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Referral Source: _______________________________________________________________________

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When was the problem first noticed? ________________________________________________________________________________________________________________________________________________________________________How has the problem changed since you first noticed it? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What has been done about it? Has this helped? ________________________________________________________________________________________________________________________________________________________________________What do you hope to learn from this evaluation and what do you think should be done? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Tell us more about previous evaluations or services provided with approximate dates:Speech therapy: ______________ Physical therapy: ____________________Occupational therapy: __________ Cook’s Children’s Hospital, DallasScottish Rite Hospital, Dallas Callier Center, DallasKlaras Center, Waco MHMR, Waco/otherChild Protective Services Counseling servicesPsychological services Public schoolAudiology Other

List diagnosis/es: ____________________________________________________________ Describe services: __________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

FamilyOther Children (including step-siblings and half-siblings, foster, adopted) :Name Age Sex In Home: School/behavioral/health Problems

Is the child adopted? ______________________ Age adopted _________________If adopted, describe the child’s relationship with the parents and/or guardian(s) Does the child have contact with his/her biological parents?: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Others living in the home:Name Age Sex Relationship School/behavioral/health Problems

Birth Mother Birth Father

Describe any learning difficulty:

__________________________________ ________________________________

Describe any behavioral problems of either parent and treatment provided:__________________________________ __________________________________________________________________ __________________________________________________________________ ________________________________

Describe any psychological or psychiatric problems of parent(s) for which treatment was received:__________________________________ __________________________________________________________________ __________________________________________________________________ ________________________________

Any parental history of Attention-Deficit/Hyperactivity Disorder? Describe treatment if any:__________________________________ __________________________________________________________________ __________________________________________________________________ ________________________________

This information is important for diagnosis and treatment. Please answer carefully and specifically. Histories

Prenatal and Birth HistoryA. Pregnancy

Length in months ________ Normal Birth _____If problems existed, please check those that apply and specify trimester:Excessive bleeding German measles Mother – bed restHigh blood pressure Diabetes SmokingPrevious miscarriage RH incompatibility Brain injuryToxemia X-ray treatment Serious accidentPremature membrane/Rupture

Mother- alcohol use /abuse

Mother – drug use / abuse

Comments or other illnesses/complications: _______________________________________________________________________________________________________________________

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_____________________________________________________________________________

Please list any medications taken during pregnancy: __________________________________________________________________________________________________________________

Was the father taking any medication or drugs at the time of conception? If so, please specify: ________________________________________________________________________________

B. BirthNormal Birth _____ APGAR Score: _____Length of labor _______ Birth weight ______ Birth length _____

If problems existed, please check those that apply: Vaginal birth C-Section BreachBreathing problems Jaundice Extended hospital stayIncubator Cyanosis SeizuresInjury Deformity InfectionAnoxia Difficult delivery Feeding difficultyCleft/ lip palate Swallowing/sucking

problemsPhysical AbnormalitiesSpecify _____________

Explain any complication related to birth _____________________________________________ ______________________________________________________________________________

Infancy and Early Childhood

Please rate your child on the following behaviors: Circle 1 if the behavior on the left was present the majority of the time. Circle 5 if the behavior on the right was present most ofthe time. Stages in between are represented by 2, 3, and 4.

Quiet and content 1 2 3 4 5 colicky and irritableVery easy to feed 1 2 3 4 5 daily feeding problemsSlept well 1 2 3 4 5 frequent sleeping problemsUsually relaxed 1 3 3 4 5 often restlessUnderactive 1 2 3 4 5 overactiveCuddly, easy to hold 1 2 3 4 5 did not enjoy cuddlingEasily calmed down 1 2 3 4 5 tantrums, headbangingCautious and careful1 2 3 4 5 accident prone, daredevilCoordinated 1 2 3 4 5 uncoordinatedEnjoyed eye contact 1 2 3 4 5 avoided eye contactLiked people 1 2 3 4 5 disliked people

Other problems or comments regarding infancy or early childhood development: ____________________________________________________________________________________________________________________________________________________________________

Did any event, health condition, separation, etc., disturb early infant/mother bonding or the developing toddler/mother relationship? If yes, please explain: ________________________

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____________________________________________________________________________________________________________________________________________________________III. Child DevelopmentYour general impression of the child’s overall development:

slow _____ normal_____ advanced_____A. Motor development

slow _____ normal ____ advanced ____Give ages at Milestones:Sat alone Crawled Reach and graspWalked Potty trained (day) Fed selfRan well Potty trained (night) Dressed selfScribbled Tied shoes Explain/note any motor difficulties: __________________________________________________________________________________________________________________________________________________________________________________________________________________

B. Speech and Language DevelopmentCan you understand your child’s speech? ______________________________________________________________________________Do others who have difficulty understanding your child’s speech? ______________________________________________________________________________Is your child aware of the problem? Explain __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tell your child’s reaction to his own speech difficulties ______________________________________________________________________________Tell the reaction of you and other family members to the problem_____________________________________________________________________________________________________________________________________________________Family history of speech/language problems __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What do you do to help your child? ____________________________________________________________________________________________________________________________________________________________If your child has difficulty producing sounds, which ones are problems? ____________________________________________________________________________________________________________________________________________________________Does your child understand words spoken to him/her? ____________________________________________________________________________________________________________________________________________________________Does he/she understand conversation? ______________________________________________Does your child repeat words or show difficulty with breaks in his speech? ______________________________________________________________________________

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______________________________________________________________________________Does your child stutter: none _____ rarely _____ occasionally _____ frequently _____If yes, then how long has this been a problem? _______________________________________________Does your child have an unusual voice quality? (loud, soft, hoarse, nasal) ______________________________________________________________________________Give other information to explain your child’s communication problem __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Fill in age that behaviors began:Cooing sounds Vocal play/babblingFirst words PhrasesShort sentences

Tell the way your child lets you know what he/she wants at this timeEye gaze PointingGestures Moves other’s hand/bodySingle words 2-3 word phrasesCrying VocalizingComplex sentences Signs / augmentative

C. Behavioral and Mental Health History Check if they apply:Behavior Home School OtherCompliant behaviorLearning problemsHigh activity level for ageDifficulty following directionsDifficulty maintaining attentionImpulsivity (not thinking before acting)Difficulty playing with othersPrefers to play by him/herselfDifficulty getting along with peersProblems with adult authorityAggressiveBehavior problemsFriendly, outgoingShyEasily distracted by:Overly sensitive to stimuliLow response to stimuliPlease describe any behaviors of your child at home that are particularly concerning you or other

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family members: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe any behavior of your child at school that is of particular concern: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child seem to be able to control his/her behavior? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Toys or activities the child prefers to play with: ____________________________________________________________________________________________________________________________________________________________

Describe any discipline difficulties: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________How do you discipline at home and how frequently do you have to discipline? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How does your child respond to discipline? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child exhibit any strange behaviors using the five senses (touch, taste, smell, sight, hear)? If so, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child have any major dislikes or unusual fears? If so, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe any special skills or areas of particular interest your child has: ________________________________________________________________________________________________________________________________________________

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Describe your child’s established routines at home: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe your child’s eating and sleeping habits: ________________________________________________________________________________________________________________________________________________

How does your child react to pain? ________________________________________________________________________________________________________________________________________________

Explain current significant family stresses ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Previous family stressors or events that you think may have had an impact on his/her development and current functioning: ___________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________Has your child ever been subject to abuse (physical, sexual, emotional)? _____________________If so, what type and when? Did your child receive any treatment? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe your child’s relationships with others his or her age throughout his/her development: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Has your child or family received any professional mental health treatment, such as individual or family counseling, group counseling, etc.? Yes No

Please list any past and current treatments, including length of treatment: ___________________________________________________________________________________________________________________________________________________________________Do you feel the treatment is/was helping or effective? Please explain:____________________________________________________________________________________________________________________________________________________________

Present personality and behavior.

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Please describe your child’s personality characteristics (friendly, outgoing, independent, affectionate, cooperative, moody, etc). ________________________________________________________________________________________________________________________________________________

Have you noticed any recent changes in your child’s behavior? ________________________________________________________________________________________________________________________________________________

Describe your child’s interactions with others in the neighborhood, community, or other leisure activities outside the home: ________________________________________________________________________________________________________________________________________________

IV. Medical HistoryIllnesses/ConditionsCheck those that apply and fill in approximate date/s:Allergies Hearing aids- which ear R LAmputations Hearing amplification deviceAsthma Hearing problemsAttention Deficit Disorder High feversAugmentative communication device HoarsenessAutism Lengthy medication treatmentAuto accidents MeaslesBehavior problems MRBraces NightmaresBrain injury ObturatorCerebral palsy Other surgery:Chickenpox Hospitalization for ________________Cleft palate/submucous cleft Pervasive Developmental DisorderCochlear implant Physical AbnormalitiesConvulsions Poor appetiteDigestive problems SchizophreniaDown’s Syndrome School phobiaDrooling SeizuresDyslexia Sensory integration disorderEar infections Serious injury:Emotional problems StutteringEncephalitis Swallowing problemsFalls frequently/balance Syndrome (other): ________________Feeding/eating problems ThumbsuckingFragile X Chromosome Disorder Tongue-tieFrequent colds Tonsillectomy and/or AdenoidectomyGlasses Tubes in earsHand preference R L Vision problems

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Head injury Vocal nodulesIs the child currently under a doctor’s care? Give diagnosis and physician’s names: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Doctor’s place of business and phone number: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What current medication is he/she taking? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Has your child been to the emergency room with a serious emergency, hospitalized, or had outpatient surgery since birth? If yes, please describe incidents along with date, duration, and where he/she was seen: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V. School HistorySchools attended: School/ Dates

Grade Level

Name of School

Academic Strengths

Academic Weaknesses

Day care/NurseryPreschoolPPCDKindergartenElementaryMiddle SchoolHigh SchoolPrivateHomeschooledHas your child been held back or repeated a grade? Y N Explain ________________________________________________________________________________________________________________________________________________Currently, what are your child’s grades? ________________________________________________________________________________________________________________________________________________

Has your child been tested at school to address developmental, learning, or speech-language difficulties? Y N

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If yes, explain Results: ________________________________________________________________________________________________________________________________________________

What special education services has your child received for difficulties in school? (check all that apply)Speech therapy ___ resource ___ self contained ____ OT ____ Other: ____

What modifications have been used in school to support your child? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How does he/she feel about school?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How did your child adjust to the school environment when he/she began school/daycare? ________________________________________________________________________________________________________________________________________________

Does your child learn easier with a particular style of learning? Explain:Auditory ________________________________________________________________Visual ________________________________________________________________Both _________________________________________________________________

Other activities your child is involved in outside of school (sports, lessons, church, tutoring, Scouts, etc.):____________________________________________________________________________________________________________________________________________________________Please give any additional information that will help us in evaluating your child: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Child’s primary physicianName_____________________________________Address _____________________________________________________Phone Number_______________________________Diagnosis ____________________________________________________

Other professionals who have treated/evaluated the child Name/Position_________________________________________________Address______________________________________________________Phone Number_______________________________Diagnosis ____________________________________________________

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I wish reports to be sent to these persons/agencies: Name _______________________________________________________Title _______________________________________________________Address _____________________________________________________Phone ________________________

Name _______________________________________________________Title _______________________________________________________Address _____________________________________________________Phone ________________________

___________________________________ __________________ ____________Signature of person completing this form Relationship to child Date

Applications may be submitted by email, fax, or mail.

Baylor University Center for Developmental Disabilities2201 MacArthur Drive, Suite 101

Waco, TX 76708 bcdd@baylor.edu

Phone: 254-537-1042Fax: (254)-224-6633

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(name of school/institution)

Baylor University Center for Developmental Disabilities (BCDD)Consent to Request Confidential Information

Client name: __________________________________Date of birth: _______________

To Whom It May Concern:

I hereby grant permission for_______________________________________________

To disclose and deliver any information requested by Baylor Center for Developmental Disabilities.

concerning my son/daughter ________________________________________________.

This may include verbal or written information regarding case history, results of

examination, impressions, and recommendations that might benefit Baylor Center for Developmental

Disabilities in treating the client.

Yes No I have been fully informed and understand the center’s request

for my consent, as described above. This information will be

released/requested upon receipt of my written consent.

Yes No I understand that my consent is voluntary and may be revoked

at any time, except where information has already been released.

Yes No I understand that Baylor University, its employees, and officers

are released from any legal responsibility or liability for disclosure of the above

information to the extent indicated and authorized herein.

Signature:____________________________________________

Relationship:_________________________________________

Date:__________________________________________________

(name of school/institution/above agency)

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