Templates by document

Case history format and therapy intake form

A case history format and intake form for each therapy, to fill in online with the family or print as a PDF.

Choose your therapy

Formats for

Case history forms by therapy

Speech therapySpeech therapy case history form and formatA speech therapy case history form for children and adults, in an open-question format, with sample answers to guide you.
Occupational therapyOccupational therapy intake form and case history formatAn occupational therapy intake form and case history format that families can fill in at home, with sample answers for each section.
Early intervention & child developmentDevelopmental case history form and formatA developmental case history form in plain language, with open questions and sample answers showing how families describe their child.
PhysiotherapyPhysiotherapy case sheet format and sampleA free physiotherapy case sheet format for the first visit, with sample entries from the complaint to the patient's goals.

The essentials

What goes in a case history form?

Referral, concerns, birth and medical history, development, languages, school or work, routine and priorities.

Contact and referral: who referred the person, who is filling in the form, and how to reach the family.
Main concerns: what worries the family most, when they first noticed it, and what they hope will change.
Birth and medical history: pregnancy and birth, hospital stays, hearing and vision checks, medicines and allergies.
Development or functional history: early development in the family's words or, for adults, life before the current difficulty.
Languages: every language at home, who speaks which, and the language of school or work.
Education or work: school, class and support, or occupation and work status.

Keep the form in sections so families can stop and return to it.

How does an intake form change by therapy?

The core questions stay. Each therapy adds the detail it needs to plan an assessment.

Speech therapy case history: languages and how much each is used, hearing, early sounds and words, feeding, and how the person communicates today.
Occupational therapy intake: dressing, eating, toileting, play, handwriting, and responses to noise, touch or movement.
ABA and behaviour therapy intake: what the behaviour looks like, when it happens, what comes before and after, and what has been tried.
Early intervention intake: family routines, who cares for the child through the day, and what the family enjoys together.
Physiotherapy case sheet: onset and course, pain, aggravating and easing factors, past injuries or surgery, and precautions.
Rehabilitation intake: prior level of function, home access, equipment, carers and the person's own goals.

The core questions stay; the detail shifts.

Case history, intake form or assessment?

The case history records what others report. The assessment records what you observe and test.

The case history records what the family and other professionals report. The assessment records what you observe and test. Keeping them apart lets you summarise history in a paragraph and spend the report on your own findings. An intake form may also add availability and consent.

What should you ask about in Indian families?

Who lives at home, who handles which routine, every language used, and the school's medium.

Ask who lives at home. In a joint family, a grandparent who looks after a child all day may know more about mealtimes than the parent who attends. Many children hear two or three languages, and the one spoken to you may not be the one used at home.

Ask about school type and medium of instruction rather than assuming English. Note earlier reports and where they came from, but write your own history from the conversation.

How much should you collect?

Only what you will use to plan the assessment and therapy.

Every extra question is a page a parent fills in while managing a child in a waiting room. Online, keep the form anonymous with initials, and add names and contact details on paper or in your clinic's records after you download.

About case history forms

A case history form, also called an intake form, collects the background a therapist needs before or at the first visit: contact and referral details, main concerns, birth and medical history, development or functional history, languages, education or work, daily routines and the family's priorities. The templates below adapt those questions for each therapy.

The case history is where a therapy relationship starts. A good form lets the family tell their story in an order that makes sense to them and gives you what you need to plan the assessment.

Indian clinics often call it a case history format or, in physiotherapy, a case sheet format. Send it ahead or complete it together at the first visit.

Questions

Is a case history form the same as an intake form?

They overlap. A case history focuses on clinical background; an intake form may add administrative details such as availability. Many clinics combine them.

Should parents fill in the case history before the first session?

It helps when they can. Many therapists still go through it together at the first visit, because conversation brings out details a form misses.

Is there a sample of a filled case history?

Each therapy form page shows a short fictional sample answer for most sections, using initials only, so you can see the level of detail that helps. Real answers come from each family.

Do the forms include developmental milestone checklists?

No. They ask families to describe development in their own words. Milestone checklists are tied to age expectations, which these templates leave to the clinician's chosen assessment.

Can I print the case history format?

Yes. Download a blank PDF and print it, or fill it in online with the family and download the completed version.

What is a physiotherapy case sheet?

The physiotherapy term, common in Indian hospitals and colleges, for the intake and history section of an assessment, often followed by the objective examination on the same sheet.

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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