CASE HISTORY FORM

Childs Name:_________________________ Date of Birth:_________________________

Address:______________________________ Phone Number:_______________________
City:__________________ Zip:______________
Any Diagnosis? If yes, what? _________________________________________________
Mothers Name:________________________ Occupation:___________________________
Address:______________________________ Phone Number:_______________________
City:__________________ Zip:______________
Fathers Name:________________________ Occupation:___________________________
Address:______________________________ Phone Number:_______________________
City:__________________ Zip:______________
Siblings:
Name

Age

Any Special Needs?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of school child attends:______________________________________________________
Any special education services? If yes, explain._______________________________________
______________________________________________________________________________
What language(s) does the child speak? What is the primary language?____________________
With whom does the child spend most of his/her time?__________________________________
Describe the childs speech and language problem._____________________________________
______________________________________________________________________________
______________________________________________________________________________
What do you think caused the problem?______________________________________________
______________________________________________________________________________
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When was it first noticed? By whom?_______________________________________________

Has the problem changed since it was first noticed?____________________________________
______________________________________________________________________________
Is the child aware of the problem?__________________________________________________
How does the child communicate (gestures, single words, short phrases, sentences)?__________
______________________________________________________________________________
______________________________________________________________________________
Does the child use speech meaningfully?

Yes

No

Can the childs parents understand speech? Yes

No

Can playmates, teachers, and relatives understand speech? Yes

No

Were there any feeding problems?(sucking, swallowing, drooling, chewing) Yes No

If yes, explain.__________________________________________________________________
Is there any history of ear infections? Yes

No

If yes, explain.__________________________________________________________________
Has any other speech-language specialists seen the child? Who and When? What were there
conclusions/suggestions?_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are there any other speech, language or hearing problems in your family? If yes,
describe.______________________________________________________________________
______________________________________________________________________________

Prenatal/Birth History
Describe mothers general health during pregnancy.____________________________________
______________________________________________________________________________
______________________________________________________________________________
Were there any unusual conditions that may have affected the pregnancy or birth? ___________
_____________________________________________________________________________

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Medical History
Describe and provide approximate age at which the child suffered the following illnesses and
conditions.
Allergies

Asthma

Chicken Pox

Colds

Convulsions

Croup

Dizziness

Draining Ear

Ear Infections

Encephalitis

German Measles

Headaches

High Fever

Influenza

Mastoiditis

Measles

Meningitis

Mumps

Pneumonia

Seizures

Sinusitis

Tinnitus

Tonsillitis

Other

Any Hospitalizations? If yes, explain._______________________________________________

______________________________________________________________________________
Any surgeries?_________________________________________________________________
Is the child taking any medication? If yes, identify.____________________________________

Developmental History
Provide approximate age at which the child began to do the following activities:
Crawl

Sit

Stand

Walk

Feed Self

Dress Self

Use toilet
Use single words (ex. No, mom, doggie etc.)

Yes

No

Combine words (ex. me go, daddy shoe etc.)

Yes

No

Name simple objects (ex. dog, car, tree etc.)

Yes

No

Use simple questions (ex. wheres doggie? etc.)

Yes

No

Engage in conversation

Yes

No

Does the child have difficulty walking, running or participating in activities which require small
or large muscle coordination?______________________________________________________
Describe the childs response to sound.______________________________________________

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Educational History
How is the child doing academically?_______________________________________________
_____________________________________________________________________________
How does the child interact with others (ex. shy, aggressive, uncooperative)_________________
____________________________________________________________________________
If enrolled for special education services, has an individual education plan been developed? If
yes, describe the goals. _________________________________________________________
_____________________________________________________________________________

Please provide any additional information that might be helpful in working with your child.

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