Client History and Program ApplicationToday’s Date_____________________________________ Form is completed by Self______ Spouse_______ Parent_____ Guardian______ (Check One)
Mailing Address (if different than above)___________________________________________ Client lives with: Self____ Spouse______ Parent_____ Guardian____ Other_____ (Check One) Is the client adopted? Yes______ No________
Client’s Name_____________________________________ Date_________________________
Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ Name________________________________________________ Age_______________ medical historyFamily 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 _____________________
Other health problems? Yes No List_____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
behaviorDoes 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 preferenceRight Mixed Left writing ____________ ____________ ____________ eating ____________ ____________ ____________ throwing ____________ ____________ ____________ brushing teeth ____________ ____________ ____________ combing hair ____________ ____________ ____________ sports ____________ ____________ ____________ other_________________ ____________ ____________ ____________ _____________________ ____________ ____________ ____________ language and reading skillsarticulation 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 relatedProblems 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 historyAge 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 HISTORYList 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 planWhat 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_________________________
Signature_________________________________________ Date_________________________
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