Child Aesthetic Developmental Therapy Doctor Note

Child Aesthetic Developmental Therapy Doctor Note

Patient Information

  • Patient’s Name: Michael Thompson

  • Date of Birth: January 15, 2055

  • Patient ID: 001234567

  • Parent/Guardian Name: Sarah Thompson

  • Contact Information: (555) 987-6543

Visit Details

  • Date of Visit: October 1, 2090

  • Session Type: Initial Evaluation

  • Duration of Session: 60 minutes

Developmental Assessment

  • Reason for Referral: Michael was referred by his pediatrician due to concerns about delayed speech and social interactions with peers.

  • Developmental History: Michael reached major milestones such as walking at 12 months and potty training by 3 years. However, his speech has been limited to single words, and he struggles with turn-taking in play.

  • Current Developmental Level: Michael demonstrates a moderate delay in expressive language skills. He can follow simple instructions but has difficulty initiating conversation and using two-word phrases.

Observations

  1. Therapy Goals:

    • Improve expressive language skills to use two-word phrases by the next evaluation.

    • Enhance social interaction skills during play with peers.

  2. Interventions Used:

    • Engaged Michael in play-based activities, incorporating visual aids and repetition of simple phrases.

    • Implemented turn-taking games to encourage social interaction.

  3. Progress Made: Michael responded positively to visual cues and was able to imitate two-word phrases during play. He showed interest in interactive activities but required prompting to initiate conversations.

Recommendations

  1. Follow-Up Appointments:

    • Weekly therapy sessions for the next three months to monitor progress.

  2. Home Exercises:

    • Parents are encouraged to engage Michael in simple storytelling using picture books to promote language development.

    • Suggest daily playtime activities that involve turn-taking games, such as board games or simple card games.

  3. Additional Referrals:

    • Consider referring Michael to a speech-language pathologist for further evaluation of speech delays.

Provider Signature

Dr. [Your Name], M.D

[Your Email]

License Number: MD123456

Note Templates @ Template.net