Special Helps from Master Enterprises Learning Center

Client’s Name_____________________________________ Date_________________________

Siblings:

Name________________________________________________ Age_______________

medical history

Family Physician_________________________________________ Telephone________________

Address_________________________________________________________________

Client’s birth weight_______ lbs._____ oz. Apgar Scores (If known) 1.________ 2.__________

Length of pregnancy___________ Complications during pregnancy and/or delivery? Yes No

Please describe____________________________________________________________

________________________________________________________________________

Age of client when parent first had any concerns about development___________________________

Pertinent medical, neurological, visual, hearing, therapeutic, psychological or educational testing:

Date Examined by Diagnosis Recommendations

______ ___________________ _____________________ __________________________

Surgeries? Yes No

Please describe____________________________________________________________

________________________________________________________________________

Broken limbs? Yes No

List Specifics

Are there any medical problems which place limitations on physical activity, etc?

List_____________________________________________________________________

Client’s Name_____________________________________ Date_________________________

Seizures? Yes No

Frequency_____________________________________ Length_____________________

Types___________________________________________________________________

Currently taking seizure medication? Yes No

List medication(s)__________________________________________________________

Seizure medication taken previously? Yes No

List medication(s)__________________________________________________________

Other medications? Yes No

List medication(s)__________________________________________________________

Describe the client’s diet___________________________________________________________

________________________________________________________________________

Excessive Daily Weekly Rarely Never

Vegetable ________ ________ ________ ________ ________

Fruits ________ ________ ________ ________ ________

Meats ________ ________ ________ ________ ________

Sugar ________ ________ ________ ________ ________

Artificial colorings ________ ________ ________ ________ ________

Dairy products ________ ________ ________ ________ ________

White flour ________ ________ ________ ________ ________

Tobacco ________ ________ ________ ________ ________

Alcohol ________ ________ ________ ________ ________

List dietary supplements and vitamins

______________________ _____________________ ______________________

Food allergies? Yes No Never Tested

______________________ _____________________ ______________________

Food cravings? Yes No Picky eater? Yes No Overeats? Yes No Poor appetite? Yes No

Client’s Name_____________________________________ Date_________________________

Allergies? Yes No

Please describe____________________________________________________________

Does client have a history of colds or sinus congestion Yes No

Does the client have a history of ear infections Yes No

Which ears have been affected? Left Right Both

Does the client have a hearing loss? Yes No

Does the client have hypersensitive hearing? Yes No

Has the client had a tympanogram? Yes No

What were the results_______________________________________________________

Has the client had an eye examination? Yes No

Does the client wear glasses or contact lenses? Yes No

Prescription_______________________________________________________________

Has the client ever received vision therapy? Yes No

Please describe____________________________________________________________

________________________________________________________________________

Has the client been diagnosed with any of the following: (Please check)

_____ near sighted _____ far sighted _____ astigmatism _____ amblyopia

_____ strabismus _____ macular problems _____ glaucoma _____ cataracts

_____ nsytagmus _____ blind _____ cortical blindness _____ other

Sleeptimes from ___________ to __________ Naps from_______________ to _______________

Client physical activity level

Daily Yes No How many days per week___________________________________

Types of activities__________________________________________________________

Duration of activities________________________________________________________

Is the client seeing a specialist? Yes No (Please check)

_____ Neurologist _____ Counselor Other________________

_____ Psychologist/Psychiatrist _____ Chiropractor _____________________

_____ Nutritionist _____ Speech therapist _____________________

_____ Physical therapist _____ Occupational therapist _____________________

_____ Vision therapist _____ Orthopedist _____________________

_____ Cardiologist _____ Tutor _____________________

behavior

Does the client have a history of emotional or behavioral disorders? Yes No

Please describe____________________________________________________________

Is there a family history of emotional or behavioral disorders? Yes No

Please describe____________________________________________________________

Client’s specific positive behaviors____________________________________________________

Client’s specific negative behaviors____________________________________________________

Do you have specific behavioral goals for the client? Yes No

Please describe____________________________________________________________

distractibility Yes No Not sure likes competitive games Yes No Not sure

short attention span Yes No Not sure avoidance behavior Yes No Not sure

hyperactive Yes No Not sure difficulty following directions Yes No Not sure

hypoactive (low activity) Yes No Not sure difficulty with parents Yes No Not sure

rigid or inflexible Yes No Not sure difficulty with siblings Yes No Not sure

impulsive Yes No Not sure difficulty with teachers Yes No Not sure

temper tantrums Yes No Not sure difficulty with peers Yes No Not sure

sucks thumb Yes No Not sure oversensitive to sounds Yes No Not sure

few or no friends Yes No Not sure overly sensitive to touch Yes No Not sure

socially immature Yes No Not sure overly sensitive to odors Yes No Not sure

perseverating tics Yes No Not sure

(talking on a topic) Yes No Not sure phobias Yes No Not sure

low frustration level Yes No Not sure emotional Yes No Not sure

overreacts Yes No Not sure overly sensitive Yes No Not sure

destructive behavior Yes No Not sure high tolerance for pain Yes No Not sure

aggressive behavior Yes No Not sure low tolerance for pain Yes No Not sure

cyclical behavior compliant Yes No Not sure

(good days/bad days) Yes No Not sure cooperative Yes No Not sure

academic out put obedient Yes No Not sure

(good days/bad days) Yes No Not sure organized Yes No Not sure

Physical motor skills (Please check problem areas)

low muscle tone ____________ athotoid movement ______________

high muscle tone ____________ ataxic ______________

coordination ____________ weak ______________

crawling ____________ balance ______________

walking ____________ other ______________

running ____________ ______________

Client’s Name_____________________________________ Date_________________________

hand preference

Right Mixed Left

writing ____________ ____________ ____________

eating ____________ ____________ ____________

throwing ____________ ____________ ____________

brushing teeth ____________ ____________ ____________

combing hair ____________ ____________ ____________

sports ____________ ____________ ____________

other_________________ ____________ ____________ ____________

_____________________ ____________ ____________ ____________

language and reading skills

articulation problems Yes No Not sure mirror writing Yes No Not sure

stammer or stutter Yes No Not sure forgetful Yes No Not sure

Aphasia Yes No Not sure right, left confusion Yes No Not sure

poor pencil grasp Yes No Not sure poor judge of time Yes No Not sure

sloppy writing Yes No Not sure poor reading ability Yes No Not sure

difficulty copying poorly organized Yes No Not sure

from blackboard Yes No Not sure letter reversals Yes No Not sure

math related

Problems with math:

computation Yes No Not sure word problems Yes No Not sure

concepts Yes No Not sure poor logic Yes No Not sure

developmental history

Age crawled (on stomach) ______ years ______ months

crept (on hands and knees) ______ years ______ months

walk ______ years ______ months

toilet trained ______ years ______ months

first word ______ years ______ months

use of couplets (two words together) ______ years ______ months

3-4 word phrases ______ years ______ months

sentences ______ years ______ months

conversational language ______ years ______ months

read ______ years ______ months

Client’s Name_____________________________________ Date_________________________

Does the client enjoy watching television? Yes No

Does the client enjoy being read to? Yes No

Does the client enjoy reading books? Yes No

Speech and language problems? Yes No

Fine motor problems? Yes No

Gross motor problems? Yes No

Does the client bed wet? Yes No

EDUCATIONAL HISTORY

List all schools attended, years attended, grade completed or degrees earned.

______________________________________________________________________________

List any educational problems.

______________________________________________________________________________

List any labels, classifications, or educational diagnoses

______________________________________________________________________________

List any exceptional abilities, academic, physical, artistic, musical. . .

______________________________________________________________________________

Lessons (musical, physical/sports, art, language, etc.

______________________________________________________________________________

Are there any events which may be currently affecting the client adversely? Yes No

Please describe____________________________________________________________

________________________________________________________________________

Client’s Name_____________________________________ Date_________________________

Goals and plan

What are your goals and expectations?

______________________________________________________________________________

Who will implement the program?_____________________________________________________

______________________________________________________________________________

Daily length of time parents can work with client?_________________________________________

Daily length of time others can work with client?__________________________________________

______________________________________________________________________________

How did you hear about our program?__________________________________________________

When did you first hear about our program? _____________________________________________

What have you done to orient yourself to our program?_____________________________________

Which book have you read, which audio/visual or live seminar have you heard/view?________________

______________________________________________________________________________

We are dedicated to assisting individuals in the achievement of their God given potentials. Further, we are continually investigating, researching and utilizing the best methods available in this endeavor. Program recommendations are not medical, therapeutic, or psychological prescriptions. Program recommendations are offered for the client and family’s review, investigation and education. Application of said procedures is the responsibility of the client and family. Maggie Dail is an educator; she is not licensed to, nor does she practice medicine nor offer medical advice. If medical or other licensed professional advice is needed the family is urged to consult with the appropriate licensed professional.

I acknowledge that I have read and completed this information to the best of my knowledge and ability, and that I understand that neither Master Enterprises Learning Center nor those trained by or employed by MELC are assuming responsibility or liability for the client, and that I, as parent, guardian, or client, assume full responsibility.

Signature_________________________________________ Date_________________________

Maggie Dail

Client History and Program Application

Country_________________________

Country_________________________

Country_________________________

medical history

behavior

hand preference

language and reading skills

math related

developmental history

EDUCATIONAL HISTORY

Goals and plan