Case History Form
Contact information
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender
*
Male
Female
Grade
*
Please Select
Pre-School
1
2
3
4
5
6
7
8
9
10
11
12
Mother's Name
*
First Name
Last Name
Preferred Phone Number
*
-
Area Code
Phone Number
Accept Text Messages
*
Yes
No
E-mail
*
Father's Name
*
First Name
Last Name
Preferred Phone Number
*
-
Area Code
Phone Number
Accept Text Messages
*
Yes
No
E-mail
*
Siblings
names, genders, ages
Your child's pediatrician/PCM
*
First Name
Last Name
Address
Clinic Name
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Area of Concern
Please describe your area(s) of concern
*
When was the problem first noticed?
*
By whom?
*
Has your child received previous help for the area(s) of concern?
*
Yes
No
Please provide type of help, dates of service and the professional/agency involved.
Are there family members/relatives with a history of communication difficulties?
*
Yes
No
Please provide additional information:
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Pregnancy and Birth History
Is there anything remarkable about pregnancy or birth?
*
Complications, accidents, etc.
Was the baby full term?
*
Yes
No
How early/late?
How long was labor?
What type of anesthesia?
Induced?
Yes
No
Cesarean?
Yes
No
Were forceps used?
Yes
No
Did the baby require oxygen?
*
Yes
No
Was s/he jaundiced?
*
Yes
No
Were there any complications immediately following the birth or during the first 6 weeks of life?
*
difficulty breathing
difficulty sucking
difficulty feeding
transfusions
seizures
birth defect
Other
Other/Additional Information
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Medical History
Does your child have a medical diagnosis?
Autism, Epilepsy, etc.
Please describe any serious illnesses, injuries or physical problems your child has experienced:
Chronic ear infections, PE tubes, tonsils, broken bones, etc.
Does your child have any allergies?
*
Yes
No
Allergies
Does your child take any medications?
*
Yes
No
Medications
Does your child use a pacifier or suck his/her thumb/fingers?
Yes
No
Does your child regularly breathe through his/her mouth? *This could be due to constant congestion or just a habit.
Yes
No
Only at night
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Speech/Language Development
At what age did the following occur?
*
Age
Additional info/explanation
Responded to own name
Followed simple directions
Recognized names of familiar objects
Pointed to named body parts
Babbled
Said first word
Vocabulary of 10 words
Combined 2 words
Talked in short sentences
Verbally related events/experiences
At the present time does your child...
*
Yes
No
follow directions correctly?
respond to questions appropriately?
require gestures for comprehension?
require frequent repetition?
require shorter sentences for comprehension?
Use this area to explain if needed.
How does your child communicate with others?
*
With sounds
With words
With sentences
With picture exchange
With speech generating device
With gestures/sign language/pointing
Not applicable
Other
How much of your child's speech do you understand?
*
%
How much of your child's speech do unfamiliar listeners understand?
*
%
Please answer the following questions:
*
Yes
No
I don't know
Does a parent/sibling interpret for your child?
Does your child struggle physically to produce sounds or words?
Does your child use the wrong word?
Does your child repeat words/phrases previously heard (echolalia)?
Does your child's voice have a harsh or nasal quality?
Does your child seem to have adequate hearing?
Does your child stutter? Do they often repeat sounds, words or phrases?
*
Yes
No
I don't know
Please select the terms that describe your child's speech
Frequent
Often
Never
Sound repetitions (I w-w-want)
Part word repetitions (I wa-wa-want)
Whole word repetitions (I want-want-want)
Prolongations (I wwww-ant)
Blocks (I ----want)
Frequent interjections (I, umm, uh, want)
Visible struggle or tension to get sounds/words out
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Educational History
Does your child receive related services from school?
*
Yes
No
Your child's school
Your child's teacher(s)
School Services
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Social and Behavioral Development
Is your child toilet trained?
*
Yes
No
Play and activities
Click to edit
What is the average length of time your child can stay playing at one activity?
What activities/toys hold your child's attention for the shortest amount of time?
What activities/toys hold your child's attention for the longest amount of time?
What are your child's preferred play activities?
Does your child avoid any play activities?
Please describe how your child interacts with other children:
*
solitary play, parallel play, cooperative play, imaginative play, etc.
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What are you hoping to achieve with speech-language therapy?
*
Other information or comments:
*
Restrictions, preferences, etc.
Form completed by (click to sign):
*
*
First Name
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