Speech Therapy Case History Form

Speech Therapy Case History Form
All of the following information is for the use of Central Texas Therapy Spot’s professional staff and will be handled in confidence.

This information will assist the staff in completing a meaningful examination. Please answer the questions as fully and accurately as possible. Thank you.
Patient's Name*

First NameLast Name
Name of Responsible Party Completing Form*

First NameLast Name
Relationship to Patient*
Date Completed*

MonthDayYear
Date

Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Patient's Pediatrician (PCP)
Fax Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Briefly describe your child's problem:
When was the problem first noticed?
What has been done about it?

HEALTH & DEVELOPMENTAL HISTORY
Is the child currently taking any medications?

YesNo
Please List:
Does the child have any known allergies?

YesNo
Please List:
Has the child had any major surgeries?

YesNo
Please List:

EDUCATIONAL & SOCIAL INFORMATION
School presently attending
Teacher
Any Additional Services
Grade Level
Any grade repeated?

YesNo
Any grade skipped?

YesNo
Does the child have serious difficulty in any subject/activity?

YesNo
If yes, what subject?
Does the child excel in any particular subject/activity?

YesNo
If yes, what subject?

ADDITIONAL COMMENTS or OTHER IMPORTANT INFORMATION
Is there any other information you feel would help us evaluate your child?
How did you hear about us?
Thank you for your time and attention in completing this history form!
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