Chatterboks Speech Therapy, P.C. & Optimal Therapy for Kids, LLC
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1 CHILDHOOD CASE HISTORY FORM Identifying and Family Information: Person completing this form: Child s Name: Birthdate: Sex: M F Father s Name: Mother s Name: Child lives with (check one): Birth Parents Foster Parents One Parent Adoptive Parents Parent and Step-Parent Other Other Children in the Family: Name Age Sex Grade Speech/Hearing Problems? Motor delays? Is there a language other than English spoken in the home Yes No If yes, which one? Does the child speak the language? Yes No Does the child understand the language? Yes No Who speaks the language? Which language does the child prefer to speak at home? Does your child currently have a medical diagnosis (syndrome, disorder)? If yes, please list: BIRTH HISTORY Was there anything unusual about the pregnancy? How old was the mother when the child was born? Was the mother sick during the pregnancy? Full term delivery? If not, please provide gestational age at birth Birthing complications? Please describe Was the child kept in the hospital for any further testing and/or treatment? Please describe:
2 MEDICAL HISTORY Has your child had any of the following? adenoidectomy tremors seizures allergies flu sinusitis breathing difficulties head injury sleeping difficulties thumb/finger sucking clumsiness/frequent falls colds tonsillectomy tonsilitis vision problems ear infections, age Frequency of ear infections ear tubes Has your child had diagnostic testing, such as genetic testing, MRI, CT, EEG, flouroscopy? Please list with date and results of testing: Other serious injury/surgery: Is your child currently (or recently) under a physician s care? If yes, why? Please list any medications, supplements and/or special diet your child uses regularly: SPEECH-LANGUAGE-HEARING Do you feel your child has a speech/language problem? Has he/she ever had a speech/language evaluation/screening? What were you told? Has your child ever had speech therapy? What was he/she working on? Do you feel your child has a hearing problem?
3 Has he/she ever had a hearing evaluation/screening? What were you told? Has your child received any other evaluation or therapy (physical therapy, occupational therapy, counseling, vision, etc.)? Is your child aware of, or frustrated by, any speech/language difficulties? What do you see as your child s most difficult problem in the home or when interacting with others? (** In other words, what keeps you up at night??) What do you see as your child s most difficult problem in school (if applicable)? VOICE DEVELOPMENT Does your child have a history of any of the following? (mark all that apply) Screaming tantrums Grunting Frequent runny nose Reflux Loud talker Loud sound effects Hoarseness (scratchy) (e.g., car noises, animal sounds) Loud whiny voice Do you feel that your child uses his voice too loudly when trying to gain adult attention? Please describe any voice concerns you may have Has your child been evaluated by an otolarygologist (ENT)? If so, please provide the date, purpose and findings DEVELOPMENTAL HISTORY Please tell the approximate age your child achieved the following developmental milestones: Speech Language Development: babbled/cooed said first words put two words together spoke in short sentences
4 Motor Development: rolled back to tummy sat alone moved into sitting crawled walked stood alone run/jump toilet trained Does your child brush his/her teeth and/or allow brushing? choke on food or liquids? currently put toys/objects in his/her mouth? drool excessively? exhibit picky eating behaviors? Explain exhibit any sensory difficulties? Explain CURRENT SPEECH-LANGUAGE-HEARING Does your child repeat sounds, words or phrases over and over? understand what you are saying? retrieve/point to common objects upon request (ball, cup, shoe)? follow simple directions (shut the door, get your shoes)? respond correctly to yes/no questions? respond correctly to who/what/where/when/why questions? Your child currently communicates using body language words (shoe, doggie, up) sentences longer than 4 words (check all that apply) 2-4 word sentences sounds (vowels, grunting) sign language and/or AAC Behavioral characteristics: (check all that apply) cooperative restless attentive poor eye contact willing to try new activities easily distracted/short attention plays alone for reasonable length of time destructive/aggressive separation difficulties withdrawn easily frustrated/impulsive inappropriate behavior stubborn self-abusive behavior
5 SCHOOL HISTORY If your child is in school, please answer the following: Name of school and grade in school: Teacher s name: Has your child repeated a grade or started late and why? What are your child s strengths and/or best subjects? Is your child having difficulty with any subjects? Is your child receiving help in any subjects? ADDITIONAL COMMENTS Thank you!
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INTAKE FORM - CHILD. Name: DOB: Age: Medical Diagnoses (of any kind): Educational Diagnoses: Reason for evaluation Parental concerns:
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