Speech Case History Information Form

Speech Case History Information
Client Name:*

First NameLast Name
School:
Grade:
Medical Information

Please provide information describing your child's past and current health.
Pregnancy and Labor (please list any illnesses or complications during pregnancy):
Was the pregnancy full-term?*

YesNo
If not, how long was the child carried?
Weight at birth:
Duration of labor:
How was the child delivered?:*

VaginalCaesareanBreechUse of forceps
Was the pregnancy induced or delayed?
Please describe the condition of the child at birth (health, jaundice, bruises, etc.):
Health

Has this child had any of the following:

	Yes	No	Please explain
Surgeries
Been Hospitalized
Serious Injury (such as head injury, broken bones)
High Fever (include how high it was and for how long)
Seizure (include when, and how it was treated)

Please list any illnesses/conditions that your child has or has had (i.e. asthma, croup, ear infections, sinus problems, tonsillitis):
Does your child currently take medication (please list)?
Does your child have any food or drug allergies?
Is this child on a special diet (if so, please describe)?
Hearing and Vision

Please list mark below regarding your child's hearing and vision:

	Yes	No	Please describe/explain:
Do you suspect your child has a hearing problem?
Has their hearing been tested? (please list when and the results)
Does your child respond to his/her name being called?
Does your child respond to environmental sounds consistently (cars, horns, sirens, doorbell, alarms, phone)?
Does your child appear confused or agitated in noisy places?
Does your child's listening seem to vary?
Does your child forget directives, assignments or requests?
Can your child follow directions? (please list if they can follow directions from spoken command only, gesture or both)
Does your child, or do you suspect, your child to have a visual impairment? (please explain)
Has your child's vision been tested? (please list when and the results)
Does your child wear glasses/corrective lenses?

Please indicate the age your child:

At what age did your child:

	Age	Please describe/explain:
Drink from a cup?
Chew solid foods?
Eat table food?
No longer breast/bottle feed? (please list if there were any difficulties)

Approximately how long does it take the child to finish a meal?
Any foods this child does not like or refuse to eat?
Please list foods your child likes to eat?
Does your child use a pacifier or has he/she in the past? If so, at what age did pacifier use discontinue?*
Does your child suck his/her thumb or has he/she in the past? If so, at what age did thumb sucking stop?*
Speech and Language Development

At what age did your child:

	Age	Please describe/explain:
Babble/string sounds together?
Use first word?
Use single words?
Put two words together (mama go)?
Form sentences:

How many words does your child use in a sentence? (please give example)
How does this child make his/her needs known (speech alone, speech and gesture, gesture only, crying and/or screaming)?

	Yes	No
Can you understand your child's speech?
Is the child's speech clear?
Is your child understood by people other than family or close friends?
Is the child aware of any speech problems?
Is he/she frustrated?

What does the child do when others do not understand him/her?
What are your concerns regarding your child's speech and language skills?
Primary language spoken at home?
Other languages spoken at home?
Is there a history of any relative(s) with speech, language, hearing, developmental delay, academic or behavioral difficulty. Please explain.
Is there a history of any relative(s) with speech, language, hearing, developmental delay, academic or behavioral difficulty? Please explain.
Are there any factors in the child's home that may relate to his/her difficulty? (marital conflict, death or illness, etc)
Motor Skills
Do you have or have you ever had concerns regarding your child's motor development?
Does your child prefer their:

Right HandLeft HandBoth
How do you feel your child's motor skills compare to his/her peers?

Does your child exhibit any of the following:

	Yes	No	If yes, please explain:
Clumsiness
Awkward Movements
Balance Difficulties
Difficulty with fine motor/hand skills
Coordination or smoothness of movement

Play and Social Skills Development
Did your child engage in play with you such as Peek-a-boo?

YesNo
How would you describe your child's interest in people?
What activities does your child prefer?
With whom does your child like to play?
Describe your child's play skills (motor play with toys, imaginative play, etc):
Self-Care

Does your child:

	Yes	No	Please explain/describe if neeeded:
Dress him/herself?
Put on shoes and socks?
Toilet train with independence?
Toilet train with assistance?
Feed him/herself?
Use a spoon?
Use a fork?
Use a knife?
Have trouble calming down once upset or agitated?
Have a regular sleep schedule?
Sleep alone?
In a crib/bed?

Personal Characteristics
Please describe your child's personality traits and general behavior (shy, outgoing, etc.):
Additional Information
Describe your child's strengths:
Describe your child's area(s) of difficulty:
What is your major area of concern for your child, if any?
What would you like to see your child gain from therapy?
Name of person who completed this form:*

First NameLast Name
Relationship to client:*
Date

MonthDayYear
Date
Please upload any files/records you would like to share with us:

Cancelof
Should be Empty:

Speech Case History Information