Pediatric Case History Form

Quick Reference

Billing Department

252-355-5535 phone
888-604-4216 fax
[email protected]

Patient Referrals

252-355-5535 phone
888-562-3240 fax
[email protected]

Career Opportunities & Contract Therapy Services

252-916-1029 phone
252-355-9218 fax
[email protected]

Patient Care Coordination

252-725-0803 phone
888-551-2163 fax
[email protected]



Our evaluation of your child’s speech, language, and hearing will depend on information about his/her past history. 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 for your appointment.

I. IDENTIFICATION




























II. AREAS OF CONCERN







III. SPEECH, LANGUAGE, AND HEARING HISTORY












If yes, which ear(s)?
How long?

If yes, date?
Results of evaluation?

IV. GENERAL DEVELOPMENT

A. PREGNANCY AND BIRTH HISTORY







If yes, please explain:






Please list any other abnormalities:




If so, describe:

B. DEVELOPMENTAL HISTORY

Please provide the approximate age at which the child began to do the following activities:

C. MEDICAL HISTORY

Please check the following as they apply to your child:
   





D. EDUCATIONAL HISTORY


Please complete the following if your child is enrolled in a public or private school
grades K-12:

When? 
Where?



E. BEHAVIOR

Please check as they apply to your child:
Stays with an activity    
Happy
Gets along with adults
Prefers to play alone
Irritable Makes friends easily
Separates easily from parents Plays with toys appropriately
Transitions well to new activities/routines Very alert to gestures, facial expressions or movements


 

“Trusted by parents, Chosen by therapists”

Contact Information

Venture Rehab Group
P.O. Box 2417
Winterville, NC 28590
[email protected]

Patient Referral Line:
252-355-5535
888-551-2163 (Fax)
Contracting & Employment:
252-916-1029

At A Glance...

Our patients are our passion! Venture is committed to providing state of the art, one on one therapy services for children, allowing them to reach their greatest potential. This is achieved through a team approach including the therapist, client and caregiver. We provide unique, innovative, “kid-friendly” interventions coupled with a high standard of professional excellence.

Speech Therapy Services

Receptive Language Therapy
Expressive Language Therapy
Articulation/ Phonology
Pre-Literacy/ Phonological Awareness
Feeding Therapy
Swallowing Therapy
Oral Motor Therapy
Fluency/Stuttering Therapy
Language / Literacy Therapy

OT Services

Fine Motor Delay
Visual Perceptual Delay
Feeding difficulties
Sensory Integrative Dysfunction
Dysgraphia (handwriting difficulty)
Gross Motor (uncoordinated)
Fine Motor Planning Problems
Attentional Difficulties
Autism Spectrum Disorders
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