SimucaseTM 2018
Completed at intake, 12 months of age
CHILD CASE HISTORY FORM
GENERAL INFORMATION:
Child’s Name: Witten
Age: 12 months
Person completing form: Sarah, mother , moter
What are your primary concerns?
Witten is not able to sit from a laying position, he cannot pull himself to a stand, and he
cannot walk. We are very concerned about this and his doctor recommended an evaluation.
What is the child’s primary language?
English
What is the parents’ primary language?
English
Who is the child’s primary caregiver?
Parents and an in-home au pair.
What is the caregiver’s primary language? English. Minimal exposure to Spanish
and Italian.
Does the child live with both parents?
yes
If no, who is the child’s legal guardians?
, FAMILY INFORMATION:
Mother’s Name Sarah
Father’s Name James
Brothers and Sisters Ages
none
EMERGENCY CONTACT INFORMATION:
Name Grandparents
REFERRAL INFORMATION:
Referred by: Dr. Singerman
Profession of
person or Witten’s Pediatrician
relationship:
Pediatrician Smile Pediatrics
Information:
PRENATAL AND BIRTH HISTORY:
During the pregnancy, did the mother experience any unusual illnesses or accidents, or require
any medication?
No, I was healthy during the pregnancy.
Length of pregnancy: 39 weeks Length of labor: 7 hours
Birth Weight: 9 lbs. 3 oz.
Type of delivery: Vaginal Caesarian
Completed at intake, 12 months of age
CHILD CASE HISTORY FORM
GENERAL INFORMATION:
Child’s Name: Witten
Age: 12 months
Person completing form: Sarah, mother , moter
What are your primary concerns?
Witten is not able to sit from a laying position, he cannot pull himself to a stand, and he
cannot walk. We are very concerned about this and his doctor recommended an evaluation.
What is the child’s primary language?
English
What is the parents’ primary language?
English
Who is the child’s primary caregiver?
Parents and an in-home au pair.
What is the caregiver’s primary language? English. Minimal exposure to Spanish
and Italian.
Does the child live with both parents?
yes
If no, who is the child’s legal guardians?
, FAMILY INFORMATION:
Mother’s Name Sarah
Father’s Name James
Brothers and Sisters Ages
none
EMERGENCY CONTACT INFORMATION:
Name Grandparents
REFERRAL INFORMATION:
Referred by: Dr. Singerman
Profession of
person or Witten’s Pediatrician
relationship:
Pediatrician Smile Pediatrics
Information:
PRENATAL AND BIRTH HISTORY:
During the pregnancy, did the mother experience any unusual illnesses or accidents, or require
any medication?
No, I was healthy during the pregnancy.
Length of pregnancy: 39 weeks Length of labor: 7 hours
Birth Weight: 9 lbs. 3 oz.
Type of delivery: Vaginal Caesarian
