Test Medical History Step 1 of 10 10% Medical/Clinical Client History FormPlease fill out your info below to get startedBCBA First Name BCBA First Name BCBA Last Name BCBA Email CONTACT INFORMATIONChild’s/Client Name: Name Date of Birth: MM slash DD slash YYYY Gender: Male Female Name of person completing this form: Name Phone Number:Mother/Primary Caregiver’s Name: Name Father/Caregiver’s Name: Name Mother/Caregiver Address:Father/Caregiver #1 Address:Mother/Caregiver Cell Phone:Father/Caregiver’s Cell Phone:Mother/Caregiver Work Phone:Father/Caregiver Work Phone:Parent Marital Status/ Family Composition:Select OneMarriedDivorcedSeparatedNever MarriedWidowedOther custody arrangementCustody Arrangements: (If never married/divorced/separated, is there a joint custody?) Yes No Is there any contact with a non-custodial parent? (i.e., Department of Child & Families)? Yes No Emergency Contact Name:Emergency Contact Phone Number: MEDICAL INFORMATIONDiagnostic Information: (DSM-5/ICD-10 Diagnostic Code) ASD DSM-5 299.0 ICD-10 F84.0 Other Diagnosing Physician’s Name:Practice Name:Date(s) of Assessment: MM slash DD slash YYYY MEDICAL INFORMATIONPrimary Care Physician (PCP) Name:PCP Phone:PCP Address:PCP Fax:Insurance Provider:Insurance ID:Group Number:Membership Number: REASON FOR REFERRALWhy are you pursuing ABA services?Who referred your child to Butterfly Effects (BE)?What are your expectations from ABA treatment and BE Services?Are there cultural or spiritual beliefs that may impact treatment? Yes No Are there any potential barriers that may impact treatment? Yes No What is your child’s availability for treatment? (Please check all available times for treatment.) TIME/DAY MON TUES WED THUR FRI SAT SUN 7:30AM–3:30PM 8:00AM–11:00AM 11:30AM–1:30PM 1:00PM–3:00PM 3:00PM–6:30PM DEVELOPMENTAL HISTORYPrenatal Complications: Yes No Postnatal Concerns: Yes No Exposure to drugs or toxins in utero: Yes No Concerns about Motor Development: (e.g.: sitting, crawling, walking). Yes No Other Problems with mobility or coordination: (e.g., ride a bike, catch a ball) Yes No Other Language Development: (e.g., single words by 12 months, twoword phrases by 24 months, sentences by 36 months) Yes No Other Does your child have difficulty following directions?Does your child have articulation or intelligibility issues?Does your child have difficulty within the social domain?Does your child have difficulty with play or leisure skills?Did your child struggle with early academic skills: (e.g., colors, letters, counting, etc.)? Yes No Other Is your child toilet trained?YesNoThird ChoiceIf yes, at what age?Is your child toilet trained through the night?YesNoThird ChoiceIf yes, at what age? MEDICAL HISTORY & INFORMATIONAny diagnosed genetic or medical conditions? Yes No Butterfly Effects does not admit a child or staff who has a diagnosed communicable disease, i.e., hepatitis, blood-borne disease, etc., (which cannot be contained by universal precautions) during the time when it is communicable. Is your child currently diagnosed with a communicable disease? Yes No Problems with vision? Yes No Concerns about hearing? Yes No Date of last hearing test: MM slash DD slash YYYY History of chronic ear infections? Yes No Tubes? Yes No Date of surgery: MM slash DD slash YYYY Heart defects? Yes No History of serious illness? Yes No Hospitalizations? Yes No Asthma? Yes No Surgeries? Yes No a. Does your child have an inhaler?b. Where is inhaler kept?c. Is child able to independently & accurate use inhaler in case of asthma attack or emergency?Serious injury (e.g., broken bones)? Yes No Seizures, convulsions, staring spells? Yes No Head injury or loss of consciousness? Yes No Environmental allergies? Yes No Food allergies? Yes No If yes, please answer: please list all foods child is allergic to:1. Is food allergy through ingestion or touch/contact?2. How severe is the allergic reaction to the above foods? Mild (child presents with minor rash or minimal discomfort) Moderate (child presents with rash, or hives) Severe (anaphylactic reaction which requires epi-pen and call to 911) 3. Does your child have an epi-pen for a severe allergy? Yes No If Yes, Where is epi-pen typically stored? *staff working with child will require epi-pen training delivery*(Required) MEDICAL HISTORY & INFORMATIONReflux, constipation, or other gastrointestinal issues? Yes No UntitledProblems with feeding or restricted diet? e.g., chewing, swallowing, history of choking) Yes No UntitledProblems with sleep (e.g., bed routine, sleep onset, waking during night, sleep walking)? Yes No UntitledHistory of sexual abuse:Perpetrator Yes No Victim Yes No Specify:History of physical abuse or neglect?History of Suicidal Behavior:Document past and present use of alcohol and/or illicit drugs:Prescription/medications Yes No Nicotine Yes No Alcohol Yes No Prescription/ medications Yes No Other Substance Yes No UntitledPlease list current medications:Name of Medication:Prescribed for:Prescribing Doctor:Please list all past medications:Name of Medication:Prescribed for:Prescribing Doctor:Does your child have any conditions in which over the counter products (such as eczema lotion, diaper rash cream, etc.) may need to be applied (by the child or parent) during services? *BE staff are not permitted to deliver medication or OTC products (unless prior written approval has been obtained for life saving measures such as an epi-pen or diastat).Does the child come into contact with secondhand smoke? Yes No UntitledPREVIOUS EVALUATIONS & TREATMENT (PLEASE PROVIDE COPIES)Any history of learning challenges within the family? (e.g., reading, writing, math) Yes No UntitledAny family of history of developmental delays (e.g., Autism, intellectual disability)? Yes No UntitledAny family history of problems with the regulation of attention or behavior? Yes No Untitled Any neurological or genetic conditions within the extended family? Yes No UntitledAny history of history of mood disorders or psychiatric conditions ((e.g., bipolar, anxiety, schizophrenia)? Yes No UntitledFAMILY MEDICAL INFORMATIONEarly Intervention EvaluationDiagnostic EvaluationPsychological/ Neuropsychological EvaluationSpeech & LanguageOccupational TherapyPhysical TherapySchool Based TestingOther specialistsSpecialty ServicesABA treatment historyFunctional Behavior Assessment (FBA) / Behavior Intervention Plan (BIP)Please describe your child’s current services including school and all private therapiesIs your child on an IEP/504 plan?Community resources being utilized: (e.g., support groups, social services, school- based services)FAMILY CULTURAL INFORMATIONWhat is the primary language spoken in the home?Is there a secondary language spoken in the home?Are translation services needed?Are there cultural or spiritual beliefs that may impact treatment?What is the preferred method of communication with the clinical team (BCBA/technician)? In person conversation Phone call Email Text message CURRENT FUNCTIONING & BEHAVIOR CONCERNSLanguage & Communication DomainPrimary mode of communication: Signs/gestures Picture supports (PECS) Device/iPad Single words Phrase speech Fluent language Please describe your child’s language and communication strengths:Please describe your concerns relative to speech, language, and communication:Socialization Domain:Please describe your child’s strengths within the interpersonal and socialization domain:Describe your concerns in the socialization domain:Play & Leisure SkillsPreference Assessment: What are your child’s favorite reinforcers (i.e. toys, games, activities)Does your child play independently?Does your child play interactively with other children or adults?Does your child engage in pretend or imaginary play?Does your child take turns with games?BEHAVIOR CONCERNSDoes your child display aggression? Hits Bites Kicks Pulls hair Towards peers Towards peers Others UntitledIntensity of aggressive behavior: Mild Moderate Severe In what situations/context does your child engage in aggression?Does your child engage in self-injury(e.g., harmful behaviors)? Head bangs Skin picks Self-bites Has self-injury caused tissue damage? Yes No Specify UntitledIntensity of self-injurious behavior: Mild Moderate Severe In what situations/context does your child engage in aggression? Does your child engage in property destruction? Breaks objects/toys Tears papers Throws items Dumps items Will destroy an entire room Breaks glass or other dangerous materials Others UntitledIntensity of property destruction Mild Moderate Severe In what situations/context does your child engage in property destruction?Does your child engage in tantrum behavior? Yes No Frequency per day:Frequency per week:Duration of tantrums:Describe a tantrum:Does your child engage in noncompliant behavior? Yes No Atypical behaviorsMotor stereotypy: Yes No Please describe any atypical behavior:Vocal stereotypy: Yes No Please describe any vocal behavior:Repetitive behaviors: Yes No Please describe any repetitive behaviors:Restrictive interests: Yes No Please describe any restrictive interests:Wanders from room: Yes No Bolting:Has left house/school Yes No Has wandered from home during overnight hours? Yes No Frequency:Date of last instance of bolting:Pica (ingests inedible objects) Yes No Objects ingested:Frequency:Date of last instance of PICA: Transportation Related IssuesRemoves seat belt? Yes No Wears safety harness? Yes No Attempts to interfere with driver. Yes No Has attempted to exit a stationary vehicle? Yes No Frequency:Date of last transportation issue:For clients 12 and older: Does your child exhibit sexual health related needs? Yes No If Yes, Please describe here:Is there any additional information that would be beneficial to share about your child?