Case History Child

Child Case History
Identifying and Family Information:
Child's Name
Birthdate

MonthDayYear
Date
Sex:

MaleFemale
Parent 1 Name
Parent 1 Daytime Phone
Parent 2 Name
Parent 2 Daytime Phone
Doctor's Name
Doctor's Phone
Child lives with (check one)

Birth ParentsFoster ParentsOne ParentOtherParent and Step-ParentAdoptive Parents

Other children in the family:

	Name	Age	Sex	Grade	Speech/Hearing Problems
Child 1
Child 2
Child 3
Child 4

Child's race/ethnic group

Caucasian, Non-HispanicHispanicAfrican-AmericanNative AmericanAsian or Pacific IslanderOther
Is there a language other than English spoken in the home?

YesNo
If yes, which one?
Does the child speak the language?

YesNo
Does the child understand the language?

YesNo
Who speaks the language?
Which language does the child prefer to speak at home?
Do you feel your child has a speech problem?

YesNo
If yes, please describe
Speech-Language-Hearing
Do you feel your child has a hearing problem?

YesNo
If yes, please describe
Has he/she ever had a speech evaluation/screening?

YesNo
If yes, where and when? What were you told?
Has he/she ever had a HEARING evaluation/screening?

YesNo
If yes, where and when? What were you told?
Has your child ever had speech therapy?

YesNo
If yes, where and when?
What was he/she working on?
Has your child received any other evaluation or therapy physical therapy, counseling, occupational

YesNo
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?
Birth History
Was there anything unusual about the pregnancy or birth?

YesNo
If yes, please describe
How old was the mother when the child was born?
Was the mother sick during the pregnancy?

YesNo
yes, please describe.
How many months was the pregnancy?
Did the child go home with his/her mother from the hospital?

lYesNo
If the child stayed at the hospital, please describe why and how long:
Medical History
sleeping difficulties

adenoidectomyencephalitisfluallergiesbreathing difficultieschicken poxcoldsear infectionsEar tubeshead injuryhigh feversMeaslesMeningitisDental issuesTongue tie/lip tieSeizuresSinusitisSleeping DifficultiesThumb/finger sucking habitTonsillectomyTonsillitisVision problemsSleep problems
Other serious injury/surgery
Is your child currently (or recently) under a physician's care?

YesNo
If yes, why?
Please list any medications your child takes regularly
Developmental History

Please tell the approximate age your child achieved the following developmental milestones:
sat alone
grasped crayon/pencil
babbled
said first words
put two words together
spoke in short sentences
walked
toilet trained
As a baby...
Was feeding a problem? Explain:
Bottle fed?Breast fed?
Age weaned from breast?
Age weaned from bottle?
Age drank independently from an open cup to finger fed self
Does your child?

choke on food or liquids?currently put toys/objects in his/her mouth?brush his/her teeth and/or allow brushing?Eat with a spoon and fork?Picky eater?Does your child eat a variety offoods?
Current Speech-Language-Hearing
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

body language.sounds vowels, gruntingwords shoe, doggy, up2 to 4 word sentences.sentences longer than four words.Other
Behavioral Characteristics

cooperativerestlessattentivepoor eye contactwilling to try new activitieseasily distracted/shortattentiorplays alone for reasonable length of timedestructive/aggressiveseparation difficultieswithdrawneasily frustrated/impulsiveinappropriate behaviorstubbornself-abusive behavior
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
Should be Empty:

Child Case History