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* 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?* Yes No If “yes”, in what situations?*Did your child’s speech and language development ever seem to stop for a period of time?* Yes No If “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* 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?* Always Occasionally Most of the time Rarely Frequently How often do relatives and friends of the family understand what your child says?* Always Occasionally Most of the time Rarely Frequently Medical/Developmental HistoryWere there any complications before or during the birth of your child?* Yes No If “yes”, please describe.*Were any medications taken during pregnancy or delivery?* Yes No If “yes”, please explain.*Has your child ever been hospitalized?* Yes No If “yes”, please complete the information below.*Describe your child’s current health. Excellent Good Fair Poor If “fair” or “poor”, please explain*Please list your child’s physicians’ names, addresses, and phone numbersName* Address* Phone*Name Address PhoneName Address PhoneDoes your child have a history of ear infections?* Yes No If “yes”, how many per year/when?* If “yes”, how were they treated?* Were tubes ever recommended or inserted?* Yes No Does your child have any other medical issues we should know of?* Yes No If “yes”, please explain.*Has your child ever received physical/occupational therapy or previous/present speech therapy?* Yes No If “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?* Yes No If “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* Name Age Name Age How does your child interact with his/her brothers and sisters?*Does anyone in your family have a speech, language or hearing impairment? Yes No If “yes”, please explain.*Was anyone in the family a “late talker”? Yes No If “yes”, please explain.*How do you discipline your child?*Are these methods effective?* Yes No Please 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?* Yes No If 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.
