CHILD CASE HISTORY FORM

Transcription

1 CHILD CASE HISTORY FORM Please fill in the information requested below, and return to the Towson University Speech & Language Center, as soon as possible before your appointment date I. General Information Child s name: Date of Birth: Gender: Address: Preferred phone # to call: Alternate Address: Person completing this form: _ Relationship to child: Language(s) spoken in the home: II. Reason for Referral Are you interested in: (1) Evaluation (2) Treatment (3) Evaluation & treatment What are your concerns regarding your child s speech or language? IWB Speech Center Child Case History p.1 (11/2014)

2 III. Background Information Parent s Name: _ Age at time of birth: Parent s Name: _ Age at time of birth: Siblings: Name Age Gender Grade Any Speech, Hearing, Medical Problems Is there any other family history of speech, language or hearing problems? Please specify: _ IV. Birth History A. Pregnancy/Delivery: Length of Pregnancy: _ Birth Weight: _ APGAR Scores (if known): Birth was: Normal Caesarean Breech Multiple Birth Was your child in the Neonatal Intensive Care Unit (NICU)? Yes No If so, for how long? Why? B. At Birth: Normal: Yes No Jaundiced: Yes No Cyanotic (blue): Yes: No IWB Speech Center Child Case History p.2 (11/2014)

3 Other (list) Were there any feeding problems? Yes No Are there any feeding problems at this time? Yes No Was the baby s activity level: Average Overactive Underactive V. Developmental History A. Motor Development Milestone Sat unsupported Crawled Walked Fed Self Toilet trained Check if your child: Falls or loses balance easily Has difficulty eating Has difficulty swallowing List age Compared to other children your child s age, describe how he or she is able to sit, stand, run, and use his or her hands: B. Speech/Language Development Milestone Babbled Used first word Put words together List age How does your child currently communicate? For example, gestures, single words, phrases, complete sentences? IWB Speech Center Child Case History p.3 (11/2014)

4 How does your child s voice sound? Normal Too high pitched Too low pitched Hoarse Nasal Does your child repeat or block sounds or words? Yes No Do they exhibit physical behaviors related to stuttering? Yes No Does your child have difficulty making any particular speech sounds? Yes No If so, which ones?_ Do others, outside your family, have trouble understanding your child? Yes: No Does your child seem to be aware of speaking differently from others? Yes No If so, describe: Does your child seem to have any difficulty understanding speech or directions? Yes No If so, describe: Is your child frustrated by his or her communication difficulties? Yes No C. Check any of the following that apply to your child: If so, when? Sucking problems Swallowing problems Feeding problems Seizures Attention Deficit Disorder Tourette s Syndrome Language Learning Disability IWB Speech Center Child Case History p.4 (11/2014)

5 Pervasive Developmental Disorder Auditory Processing Disorder Seizure Disorder Hearing Loss Frequent ear infections PE Tubes Hearing Aids Autism Cleft Lip and/or Palate Pierre Robin Sequence Down syndrome Developmental Delays Asperger Syndrome Does your child have any other medical problems? Yes No Please specify Does your child have any allergies? Yes No Please specify Does your child take any current medications? Yes No Please specify below. Medication Dosage Frequency VI. Previous evaluations Type of evaluation When/where Results IWB Speech Center Child Case History p.5 (11/2014)

6 VII. Previous Treatment Type of treatment (e.g., speech, OT, PT) When/where Goals of treatment VIII. Educational and Emotional History 1. What school is your child enrolled in?grade? 2. Does your child have an Individualized Education Plan (IEP) for school-based services? Yes No If yes, what services are provided on the IEP? 3. Has your child ever received special help or been in a special class in school? Yes No If yes, explain briefly. 3. Has your child exhibited any social and/or emotional problems? Yes No If yes, explain briefly. IWB Speech Center Child Case History p.6 (11/2014)

7 IX. Comments Please provide any additional information that will aid us in evaluating this child. IWB Speech Center Child Case History p.7 (11/2014)