Case History Form Step 1 of 5 20% Child Case HistoryPlease answer all questions as completely as possible. The information you provide is very helpful in planning your child’s plan of care. Please note “N/A” where necessary.Name of child* First Last Name by which your child is called*Date of birth* Date Format: MM slash DD slash YYYY Age*GenderFemaleMaleParent name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone # (Home)*(Work)(Cell):Email Address* Referred by*Telephone #Name of person completing this form:*Relationship:*Person to contact in case of emergency*Telephone # Communication HistoryPlease describe your child’s communication difficulty.*When did you first notice your child’s communication difficulty?*What do you think caused your child’s communication difficulty?*Does your child’s communication difficulty ever become better or worse?*YesNoIf “yes”, in what situations?*Did your child’s speech and language development ever seem to stop for a period of time?*YesNoIf “yes”, please explain.*Describe any problems that appear to be related to your child’s communication difficulty?*Indicate the age at which your child:Please write “NA” if not applicable:Began to babble*Said first words*Said first words*Began to say two-word sentences*Began to say three-word sentences*Had a vocabulary of 50 words*Began asking questions*Sat up*Crawled*Walked*How long are your child’s typical sentences (number of words)?*How often do you understand what your child says to you?*AlwaysOccasionallyMost of the timeRarelyFrequentlyHow often do relatives and friends of the family understand what your child says?*AlwaysOccasionallyMost of the timeRarelyFrequently Medical/Developmental HistoryWere there any complications before or during the birth of your child?*YesNoIf “yes”, please describe.*Were any medications taken during pregnancy or delivery?*YesNoIf “yes”, please explain.*Has your child ever been hospitalized?*YesNoIf “yes”, please complete the information below.*Describe your child’s current health.ExcellentGoodFairPoorIf “fair” or “poor”, please explain*Please list your child’s physicians’ names, addresses, and phone numbersName*Address*Phone*NameAddressPhoneNameAddressPhoneDoes your child have a history of ear infections?*YesNoIf “yes”, how many per year/when?*If “yes”, how were they treated?*Were tubes ever recommended or inserted?*YesNoDoes your child have any other medical issues we should know of?*YesNoIf “yes”, please explain.*Has your child ever received physical/occupational therapy or previous/present speech therapy?*YesNoIf “yes”, please list below:Type of Service | Dates of Service | Name of Therapist and Address*What was the result of the therapy?*Is your child currently taking any medications?*YesNoIf “yes”, please list name of medication and reason for prescription.* FAMILY HISTORYParent Name* First Last Age*Occupation*Employer*Parent Name First Last Age*Occupation*Employer*Name (s) and age (s) of other children in the family:Name*Age*NameAgeNameAgeHow does your child interact with his/her brothers and sisters?*Does anyone in your family have a speech, language or hearing impairment?YesNoIf “yes”, please explain.*Was anyone in the family a “late talker”?YesNoIf “yes”, please explain.*How do you discipline your child?*Are these methods effective?*YesNoPlease explain.What activities do you participate in with your child? Educational / Social HistoryPlease provide the name of your child’s school and type of program he is currently enrolled along with the name of his classroom teacher. Name of school*Type of program*Name of teacher*Is your child currently receiving speech/language therapy?*YesNoIf so, please list the name and contact information of his therapist and brief summary of the goals in his therapy program.*How does your child interact with other children/siblings?*What are your child’s favorite activities, toys, and interests?*What things does your child do particularly well?*Additional CommentsPlease provide any additional information which might be helpful to us in understanding your child’s speech, language, social and overall communication skills.
