Child Case History Form

General Information Childs Name: Sex: M F Age: Daytime Phone: Cell Phone: Mothers Occupation: Fathers Name: Fathers Address: Business Phone: Age: Daytime Phone: Cell Phone: Fathers Occupation: Business Phone: no Date of Birth:

Mothers Name: Mothers Address:

May we contact you by e-mail regarding your child?: yes E-mail address: Child lives with (please circle one): Birth Parents Foster Parents Parent and Step-Parent Referred By: Other: Phone: One Parent

Adoptive Parents

Pediatrician:

Phone:

Brothers and Sisters (include names, ages, and any history of speech or hearing problems):

Is there a language other than English spoken in the home? If yes, which one(s)?

Does your child speak the language? Does your child understand the language?

Who speaks the language?

What language does your child primarily speak?

With whom does your child spend most of his or her time?

Speech, Language and Hearing: Describe your concerns about your childs speech-language development.

When were concerns first noticed? By whom?

What do you think may have caused the speech/language difficulties?

Have the difficulties changed since they were first noticed? How?

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

Have any other speech-language specialists seen your child? Who and when? What were their conclusions or suggestions?

Have any other specialists (physicians, psychologists, special education teachers, etc.) seen your child? If yes, indicate what type of specialist, when the child was seen, and the specialists conclusions or suggestions.

Do you think your child has any hearing difficulties?

Are there any other speech, language, or hearing problems in your family? If yes, please describe.

What do you see as your childs most difficult problem in the home?

Does your child... 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... (please circle all that apply): Body language 2 to 4 word sentences Sounds (vowels, grunting) Gestures Words (shoe, ball)

Sentences longer than four words.

Other _____________________________ Behavioral Characteristics (please circle all that apply): cooperative restless attentive appropriate eye contact shy withdrawn friendly

willing to try new activities

easily distracted/short attention destructive/aggressive perfectionist

plays alone for reasonable length of time separation difficulties impulsive

easily frustrated

inappropriate behavior

stubborn

self-injurious behavior

Prenatal and Birth History Mothers general health during pregnancy (illnesses, accidents, medications, etc.).

Length of pregnancy: General condition: Circle type of delivery: head first

Length of labor: Birth weight: feet first breech Caesarian

Were there any unusual conditions that affected the pregnancy or birth?

Medical History Provide the approximate ages at which your child suffered the following illnesses and conditions: Allergies: Colds: Dizziness: Encephalitis: High Fever: Measles: Pneumonia: Tinnitus: Asthma: Convulsions: Draining Ear: German Measles: Influenza: Meningitis: Seizures: Tonsillitis: Chicken Pox: Croup: Ear Infections: Headaches: Mastoiditis: Mumps: Sinusitis: Other:

Has your child had any surgeries? If yes, what type and when (e.g. tonsillectomy, tube placement, etc.)?

Describe any major accidents or hospitalizations.

Is your child taking any medications? If yes, please identify.

Have there been any reactions to medications? If yes, please identify.

Developmental History Provide the approximate age at which your child began doing the following activities: Crawl: Walk: Use toilet: Use single words (e.g. no, mom, doggie): Combine words (e.g. me go, daddy shoe): Name simple objects (e.g. dog, car, tree): Use simple questions (e.g. Wheres doggie?): Engage in conversation: Does your child have any difficulty walking, running, or participating in any other activities which require small or large muscle coordination? Sit: Feed Self: Stand: Dress Self:

Are there, or have there ever been feeding problems (e.g. problems with sucking, swallowing, drooling, chewing, etc.)? If yes, please describe.

Describe your childs response to sound (e.g. responds to sounds, responds to loud sounds only, inconsistently responds to sounds, etc.)

Educational History School: Teacher(s): How is your child doing academically (or pre-academically)? Grade:

Does your child receive special services? If yes, please describe.

If enrolled for special education services, has an Individualized Educational Plan (IEP) been developed? If yes, describe the most important goals.

What are your childs strengths and/or best subjects?

Provide any additional information that might be helpful in the evaluation or remediation of your childs speech/language difficulties.

Person completing form: Relationship to child: Signed: Date: