SPEECH ASSESSMENT CASE HISTORY FORM
Child's Name:
First Name
Last Name
DOB:
Date today:
-
Month
-
Day
Year
Date
Person Completing Form(relationship to child):
Child's Race/ Ethnicity:
Gender:
Age:
Parent/Guardian Name(s):
Preferred Phone No.
Other Phone No.(s)
Address:
Preferred email(s) for correspondence:
Other email(s):
Parent's Occupation(s):
How did you hear about For Goodness Speech, LLC?:
Doctor's Name:
Doctor's Phone:
FAMILY HISTORY
Child lives with:
Please Select
Birth Parents
Adoptive Parents
One Parent
Parent & Step-Parent
Foster Parent
Other
SIBLINGS:
NAME
AGE
SIBLING 1
SIBLING 2
SIBLING 3
SIBLING 4
SIBLING 5
Do any of the family members has a history of the following:
YES
NO
Family Member Name
Speech-Language Difficulties
Learning Disabilities:
(ex. dyslexia)
Hearing Impairment/Deafness:
If you responded "YES" to any of the above, please explain:
Is any language other than English spoken in the home?
YES
NO
If YES which language?
Does the child speak this language?
YES
NO
Does the child understand this language?
YES
NO
Which language does the child prefer to speak at home?
Why is this speech evaluation being requested?
SPEECH ASSESSMENT CASE HISTORY FORM (Page 2)
BIRTH HISTORY
Was the child born premature?
YES
NO
If YES at how many weeks?
Was the child healthy at birth?
YES
No
If NO, please explain:
Was there anything unusual about the pregnancy or delivery?
Yes
No
If YES, please explain:
MEDICAL HISTORY
Check all that apply:
Tonsilitis
Adenoidectomy
Tonsillectomy
Difficulty Sleeping
Snoring
Breathing Difficulties
Frequent colds
Seasonal Allergies
Nasal congestion
Chronic Ear Infections
Hearing loss
Ear (PE) tubes
Vision Problems
Wear glasses
Head Injuries
Other medical/genetic
Diagnoses:
Additional medical information (surgeries, hospitalizations, medications, etc.):
Date of last hearing screening
-
Month
-
Day
Year
Date
Location:
Results:
Please Select
Pass
Fail
Date of last vision screening:
-
Month
-
Day
Year
Date
Location:
Results:
Please Select
Pass
Fail
Feeding/Eating History
Check all that apply:
Thumb/finger sucking
Pacifier Use
Difficulty Nursing
Reflux/Colic
Tongue thrust
Messy Eater
Limited diet
Food texture sensitivity
Drooling observed
Tongue or lip tie present
Food allergies
Weight issues
Picky eater
Choking/coughing while eating
Sensitive gag reflex
If you check any of the above, please explain:
Was your child
Bottle fed
Breastfed
How long?
Does your child primarily breath through their...
nose
mouth
unsure
SPEECH ASSESSMENT CASE HISTORY FORM (Page 3)
Developmental History
Indicate the approximate age at which your child reached the following milestones:
AGE
Sat alone
Walked
Grasp crayon/pencil
Crawled
Toilet trained
Began to scribble/draw
Do you consider any physical/motor milestone to be delayed or impaired?
Yes
No
If YES, please explain:
Check all that apply:
Unusually active/fidgety
Easily overwhelmed
Low muscle tone
Overly sensitive to sound
Clumsy
Overly sensitive to touch
If you checked any of the above, please explain:
Has your child been diagnosed with a developmental disability or behavioral disorder?
Yes
No
If YES, please specify:
Educational/Academic History
Does your child attend school?
Yes
No
Child's school/district:
Teacher:
Grade:
Does your child have an active IFSP or IEP?
Yes
No
If yes, what service(s) does he/she receive?
Does your child have an active 504 plan?
Yes
no
If yes, under what eligibility/diagnosis?
Does your child receive any other therapies outside of school?
Yes
No
If yes, please list:
Has your child ever received a speech/language evaluation?
Yes
No
If yes, when and by whom?
Has your child received speech/language therapy previously?
Yes
No
If yes, when and by whom?
Is your child reading?
Yes
No
Did they have or are they having a difficult time learning to read?
Yes
No
Is your child having difficulty with a particular subject?
Yes
No
If yes, which subject(s)?
Has your child ever repeated a grade?
Yes
No
If so, what grade and why?
Is your child receiving any other help at school/home (e.g tutoring etc.)?
Yes
No
If yes, please list?
Speech Assessment Case History Form (page 4)
Speech & Language Development
Indicate the approximate age at which your child reached the following milestones:
Age
Babbled
Said first words
Put two words together
Spoke in short sentences
YES
NO
Unsure
1. Was your child a quiet infant (limited vocalizations/babbling)?
2. Did your child produce any consonant sounds in babbling by 12 months? (e.g. "mmm", "dah", etc.)
3. Did your child produce consonant +vowel syllables by 18 months?
(e.g. "doo", "buh,"no", etc.)
4. Did your child produce /k/ or /g/ sounds in their babbling?
(e.g. "goo", "gah", "kah", etc.)
5. Did your child have 5 or more consonant sounds at 2 years old?
6. Did/does your child prefer to use /m/,/p/, or /b/ sounds over others?
7. Did anything concern you about your child's speech development?
If yes or unsure, please explain:
Does your child prefer to communicate with :
gestures
words
both
neither
Does your child:
YES
NO
Follow simple directions?
Follow complex or multi-step directions?
Ask questions?
Understand what your are saying?
Identify actions and objects easily?
Respond correctly to yes/no questions?
Is your child speech easily understood by most people?
If you checked "NO" for any of the above, please explain:
Is your child aware or frustrated by any speech difficulties?
YES
NO
If yes, please explain:
What are your specific concerns regarding your child's speech?
Please provide some examples of a typical sentence or utterance your child says:
Submit
Should be Empty: