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SPEECH-LANGUAGE-HEARING CASE HISTORY FORM

Identifying and Family Information:

Child’s Name: ___________________________________________________________

Birthdate:____________________________________________________ Sex: ❑ M ❑ F

Father’s Name:__________________________________________________________

Address:_______________________________________________________________

Daytime Phone:__________________________________________________________

Cell Phone:_____________________________________________________________

E-mail:_______________________________________________________________

Mother’s Name:__________________________________________________________

Address:_______________________________________________________________

Daytime Phone:__________________________________________________________

Cell Phone:_____________________________________________________________

E-mail:_______________________________________________________________

 

Doctor’s Name: __________________________________________________________

Doctor’s Phone:__________________________________________________________

 

Child lives with (check one):

❑ Birth Parents  ❑ Parent and Step-Parent  ❑ One Parent  ❑ Adoptive Parents  ❑ Foster Parents ❑ Other ___________

Other children in the family: (Age/Sex Grade /Speech-Hearing Problems)

Name:________________________________________________________________

Name:________________________________________________________________

Name:________________________________________________________________

Name:________________________________________________________________

Child’s race/ethnic group:

❑ Caucasian/Non-Hispanic ❑ Hispanic ❑ Native American ❑ Asian or Pacific Islander  ❑ African-American  ❑ Other ___________

Is there a language other than English spoken in the home?

Does the child speak the language? ❑ Yes ❑ No

Does the child understand the language? ❑ Yes ❑ No

Who speaks the language? ________________________________________________

Which language does the child prefer to speak at home? _________________________

If yes, which one?________________________________________________________

Speech-Language-Hearing

Do you feel your child has a speech problem?  ❑ Yes ❑ No.  If yes, please describe. ______________________________________________________________________________________________________________________________________________________________________________

Do you feel your child has a hearing problem?  ❑ Yes ❑ No. If yes, please describe. ______________________________________________________________________________________________________________________________________________________________________________

Has he/she ever had a speech evaluation/screening?  ❑ Yes ❑ No. If yes, where and when? ______________________________________________________________________________________________________________________________________________________________________________

What were you told? ______________________________________________________________________________________________________________________________________________________________________________

Has he/she ever had a hearing evaluation/screening?  ❑ Yes ❑ No.  If yes, where and when? ______________________________________________________________________________________________________________________________________________________________________________

What were you told? ______________________________________________________________________________________________________________________________________________________________________________

Has your child ever had speech therapy?  ❑ Yes ❑ No.  If yes, where and when? ______________________________________________________________________________________________________________________________________________________________________________

What was he/she working on? ______________________________________________________________________________________________________________________________________________________________________________

Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)?  ❑ Yes ❑ No.  If yes, please describe.

______________________________________________________________________________________________________________________________________________________________________________

Is your child aware of, or frustrated by, any speech/language difficulties?______________________________________________________________________________________________________________________________________________________________________________

What do you see as your child’s most difficult problem in the home? ______________________________________________________________________________________________________________________________________________________________________________

What do you see as your child’s most difficult problem in school?______________________________________________________________________________________________________________________________________________________________________________

Has your child had any of the following?

❑  adenoidectomy  ❑  allergies  ❑  breathing difficulties  ❑  chicken pox  ❑  colds  ❑  ear infections How often?__________  ❑  ear tubes  ❑ encephalitis  ❑ flu  ❑ head injury  ❑ high fevers  ❑ measles  ❑ meningitis  ❑ mumps  ❑ scarlet fever  ❑ seizures  ❑ sinusitis  ❑ sleeping difficulties  ❑ thumb/finger sucking habit  ❑ tonsillectomy  ❑ tonsillitis  ❑ vision problems

 

Birth History

Was there anything unusual about the pregnancy or birth?  ❑ Yes ❑ No.  If yes, please describe. ______________________________________________________________________________________________________________________________________________________________________________

How old was the mother when the child was born? _______________

Was the mother sick during the pregnancy?  ❑ Yes ❑ No.  If yes, please describe. ______________________________________________________________________________________________________________________________________________________________________________

How many months was the pregnancy?___________

Did the child go home with his/her mother from the hospital?  ❑ Yes ❑ No.  If child stayed at the hospital, please describe why and how long. ______________________________________________________________________________________________________________________________________________________________________________

 

Medical History

Other serious injury/surgery: ______________________________________________________________________________________________________________________________________________________________________________

Is your child currently (or recently) under a physician’s care?  ❑ Yes ❑ No.  If yes, why?______________________________________________________________________________________________________________________________________________________________________________

Please list any medications your child takes regularly: ______________________________________________________________________________________________________________________________________________________________________________

 

Developmental History

Does your child…

Please tell the approximate age your child achieved the following developmental milestones:

__________ sat alone  __________ babbled  __________ put two words together  __________ walked

__________ grasped crayon/pencil __________ said first words __________ spoke in short sentences __________ toilet trained

Does your child…

❑ choke on food or liquids?
❑ currently put toys/objects in his/her mouth? ❑ brush his/her teeth and/or allow brushing?

Current Speech-Language-Hearing

❑ repeat sounds, words or phrases over and over?
❑ understand what you are saying?
❑ retrieve/point to common objects upon request (ball, cup, shoe)? ❑ follow simple directions (“Shut the door” or “Get your shoes”)?
❑ respond correctly to yes/no questions?
❑ respond correctly to who/what/where/when/why questions?

Your child currently communicates using…

❑ body language.
❑ sounds (vowels, grunting).
❑ words (shoe, doggy, up).
❑ 2 to 4 word sentences.
❑ sentences longer than four words.
❑ other _____________________________.

Behavioral Characteristics:

❑ cooperative
❑ attentive
❑ willing to try new activities
❑ plays alone for reasonable length of time ❑ separation difficulties
❑ easily frustrated/impulsive
❑ stubborn
❑ restless
❑ poor eye contact
❑ easily distracted/short attention ❑ destructive/aggressive
❑ withdrawn
❑ inappropriate behavior
❑ self-abusive behavior

 

School History

If your child is in school, please answer the following:

Name of school and grade in school: ______________________________________________________________________________________________________________________________________________________________________________

Teacher’s name: ______________________________________________________________________________________________________________________________________________________________________________

Has your child repeated a grade? ______________________________________________________________________________________________________________________________________________________________________________

What are your child’s strengths and/or best subjects? ______________________________________________________________________________________________________________________________________________________________________________

Is your child having difficulty with any subjects? ______________________________________________________________________________________________________________________________________________________________________________

Is your child receiving help in any subjects? ______________________________________________________________________________________________________________________________________________________________________________

 

Additional Comments: _______________________________________________________________________________________________________________________________________________________________

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