Child Case History

Telephone Numbers


Emergency Contact

COMMUNICATION HISTORY

4. Does your child’s communication difficulty ever become better or worse?

5. Did your child’s speech and language development ever seem to stop for a period of time?

7. Indicate the age at which your child did the following. Please write "NA" if not applicable:
Began to babble

Said first words

What were the first words?

Began asking questions

Sat up

Crawled

Walked

Had a vocabulary of 50 words

Began to say 2-word sentences

Began to say 3-word sentences


Please provide examples

How often do you understand what your child says to you?

How often do relatives and friends of the family understand what your child says?

MEDICAL/DEVELOPMENTAL HISTORY

1. Were there any complications before or during the birth of your child?

2. Were any medications taken during pregnancy or delivery?

3. Has your child ever been hospitalized?

If "yes," please complete the information below

Reason for hospitalizations, Date(s), Length of Stay


4. Describe your child's current health.

If "fair" or "poor," please explain:

5. Please list your child’s physicians’ names, addresses, and phone numbers.