CCABA - Child Information and Medical History

Medical Information
Diagnosis:
Name and Credential of Diagnostician*
Date of Autism (F84.0) Diagnosis*

MonthDayYear
Diagnostic Evaluation Tool(s) / Date *
Additional Diagnosis
(List all that apply)
Referring Doctor Information:
Name and Credential
Phone Number
Email Address
Address
Medications and alternative remedies (if applicable): Please list any medications child takes, or other remedies used as medical treatments. Note: KBH staff are not able to give any medication. If any medications need to be administered during session, the parent/guardian would need to be on site to do so.

Allergies: Please list any known or possible allergens, the child’s typical reaction to the allergen, and procedures followed if he/she/we encounter a reaction:

Does your family utilize any alternative treatments? If so, please describe. (e.g., brain balance, stem cell, CBD oil, homeopathy, vitamin D injections)
Food Sensitivities & Dietary Restrictions: Please list any known, observed, or possible dietary restrictions or sensitivities, the child’s typical reaction to the food, and procedures followed if he/she/we encounter a reaction:

What are common responses with your child if they undergo a change to medication, encounter allergens, have a food sensitivity? (e.g., do they get excessively sleepy, have an increase in energy, other)?
Other Medical Considerations:
Please describe any relevant medical history
Please list any medical devices used daily
Please describe any relevant family medical and psychological history
Applied Behavioral Analysis (ABA) History:
Has you child had ABA therapy before?*
Previous ABA Provider(s) Names(s)*
Pleas list all previous providers
What was your child's age range during previous ABA treatment?*
What was the average number of hours / week of previous ABA Service*
Date previous ABA services started*

MonthDayYear
Date previous ABA services ended*

MonthDayYear
Other Therapeutic History:
Has your child ever received other therapeutic services?*
Other therapeutic service types:*

OccupationalPhysicalSpeechPsychotherapyOther
Provider(s) Name(s) / Organization(s)*
Please list all previous providers
Average hrs / week for each service*

Child Information and Medical History