! SPEECH YOUTH CASE HISTORY
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- Ophelia Andra Jacobs
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1 SPEECH YOUTH CASE HISTORY Instructions: Please provide as much information as you can recall for each of the categories below, and bring the completed form with you to your appointment. Name: Date of Birth: Age: Parent/Responsible Party: Social Security #: Address with zip code: Mother s home phone: Cell/work phone: Father s home phone: Cell/work phone: Person Completing Form: Language spoken at home Description of Present Concern/difficulty: Please describe the present speech/language/academic concern/difficulty: How long ago was this concern/difficulty first noticed? By whom?
2 What do you feel is the origin of the concern/difficulty? Has the concern/difficulty become worse over time, or has it seemed to improve? Are there any conditions that make the concern/difficulty seem more or less severe? What strategies have been used to work on the concern/difficulty at home? Please describe the child/adolescent s attitude toward the concern/difficulty. What are the attitudes of others? How does the child/adolescent understand and use verbal language at home (i.e., following directions, communicating with others)?
3 Evaluation History Has the child/adolescent had any previous assessments? Yes NO If yes, please provide as much information as you can remember. What kind of evaluation? What were the results? Which tests were given? Has the child/adolescent ever received therapy services? Yes NO If yes, please provide o o o What kind Where How long ago
4 School History Please provide information where applicable: School Attended Special difficulties Preschool: Kindergarten: Elementary: Middle/ Jr. High: High School: What grade or academic level is the child/adolescent presently in? Where? Have any grades been repeated? Please explain. Does/did the child/adolescent like school? What are their best subjects? Worst? Has the child/adolescent received any special services? Please describe.
5 Please describe the child/adolescent s skills in each of the following areas, if applicable: o Paying attention: o Staying on task : o Completing assignments: o Working independently: o Following directions: o Listening comprehension (understanding what s heard): o Taking notes: o Verbal explanations, descriptions: o Paraphrasing/putting ideas in own words: o Summarizing information verbally: o Reading comprehension: o Written language (i.e., papers, essays): o Study skills: o General organization: o Test taking: o Handwriting:
6 o Other areas: Birth History Did the mother receive any medications during her pregnancy? Were there any medical complications prior to, or during birth? Was the child full term? Was the birth weight high, within normal limits, or low? Describe any atypical behaviors, congenital concerns, or medical concerns present at birth:
7 Speech language Development Please indicate the ages at which the following were noticed: Babbling: First single words: 2 word sentences: 3-4 word sentences: Speaking in sentences: Did the child/adolescent have any articulation/speech, or sound productions errors which did not seem appropriate for his/her age? Has the child/adolescent received any previous speech/language evaluations or therapy? If yes, where and when? Are there any current concern/difficulties with communication skills such as vocabulary, sentence structure, speech production, stuttering, voice characteristics, etc.? Has the child/adolescent had a hearing test? If yes, when? What were the results? Please list all languages spoken at home, daycare, and/or school, and approximately what percentage of the time each language is spoken.
8 Does anyone in the family have difficulty with learning, hearing, speech or motor skills? Yes NO If yes, please describe difficulties/problems below: Medical History Give ages at which the child/adolescent had any significant illnesses or diseases (i.e., mumps, measles, meningitis, rubella, etc.). Describe any accidents or injuries the child/adolescent has had, if hospitalized, how severe, and age at time of occurrence. Did or does the child/adolescent have middle ear infections? When? How severe? Does the child/adolescent have allergy problems?
9 Does the child/adolescent have a history of seizures, convulsions, or loss of consciousness? Are there any other medical conditions or concerns? Please list any medications the child/adolescent is taking and dosage: Motor Development Please describe the child/adolescent s motor skills, as listed: o Fine motor (i.e., writing, drawing, etc.): o Gross motor (i.e., running, kicking, walking, etc.): Describe the child/adolescent s development of early motor skills, such as standing, walking, feeding self, etc., as average, advanced, or delayed.
10 Is the child/adolescent right or left handed? Family information Please list all persons with whom the child/adolescent lives, including ages of siblings: If the child/adolescent does not live with both natural parents, please describe the living situation: Mother s name: Occupation: Age: Father s name: Occupation: Age:
11 What are the child/adolescent s favorite leisure activities and/or interests? Does the child/adolescent get along with peers, family members, etc.? Is behavior and/or discipline a concern/difficulty? At home? At school?
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