Case History Form

w. speechlanguagecorner.com p. 704.626.7727 f. 704.626.7727 e. speechlanguagecorner@gmail.com
CASE HISTORY FORM
IDENTIFYING AND FAMILY INFORMATION:
Child’s Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Sex:
Child lives with (check one)
Please list the name, age, sex, grade of other children in the family:

Rows	Yes	No	Enter Text
Is there a language other than English spoken in the home?
If yes, which one?
Does your child speak the other language spoken in the home?
Does your child understand the language spoken in the home?
Who speaks the other language spoken in the home?
Which language does your child prefer to speak at home?

PATIENT HISTORY
Describe in your own words the type of difficulty your child is having (i.e., what are your specific concerns):
When was the problem first noticed?
Does your child have any medical conditions?
Is your child currently on any medications?
Please list any medications your child takes regularly:
BIRTH HISTORY
Was there anything unusual about the pregnancy or birth?
If yes, please describe:
How old was the mother when the child was born?
Was the mother sick during the pregnancy?
If yes, please describe.
How many months was the pregnancy?
Did the child go home with his/her mother from the hospital?
If child stayed at the hospital, please describe why and how long.
MEDICAL HISTORY
Has your child had any of the following?
Other serious injury/surgery:
Is your child currently (or recently) under a physician’s care?
Please list any medications your child takes regularly:
DEVELOPMENTAL HISTORY

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

CASE HISTORY FORM