Child Aesthetic Developmental Therapy Doctor Note

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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

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