The George Washington University Speech & Hearing Center Speech ...

The George Washington University Speech & Hearing Center Speech Therapy Child Case History Form

General Information Child's Name: ________________________________________________ Date of Birth: _ _____________________

Address: _ _____________________________________________________ Phone: _____________________________

City:

__________________________________________________________ State: _ ________ Zip:

________________

Does the child live with both parents? _ ____________________________________________________________

Mother's Name: _ _____________________________________________ Age:_ ________________________________

Occupation: __________________________________________________ Work Phone:_ ______________________

Father's Name:_ ______________________________________________ Age:_ ________________________________

Occupation: __________________________________________________ Work Phone:_ ______________________

Pediatrician: _________________________________________________ Phone:_ _____________________________

Family Doctor: _______________________________________________ Phone:_ _____________________________

Referred By:_ _________________________________________________ Phone:_ _____________________________

Brothers and Sisters (include names and ages):

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What languages does the child speak?

What is the child's primary language?

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What languages are spoken in the home?

What is the dominant language spoken?

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With whom does the child spend most of his or her time?

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Describe the child's speech--language problem (e.g. voice, stuttering, expressive/receptive language delay, articulation, reading difficulty, etc.).

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How does the child usually communicate (gestures, single words, short phrases, sentences)?

Please give examples.

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When was the problem first noticed?

By whom?

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What do you think may have caused the problem?

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Has the problem changed since it was first noticed?

If yes, explain.

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Is the child aware of the problem? If yes, how does he/she feel about it?

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Have any other speech--language specialists seen the child?

Who and when?

What were their conclusions or suggestions?

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Have any other specialists (physicians, psychologists, special education teachers, etc.) seen the child?

If yes, indicate the type of specialist, when the child was seen, and the specialist's conclusions or suggestions.

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Are their any incidences of any of the following conditions among the child's family/close

relatives (maternal and paternal)?

Yes

No

Please describe

Speech Problems

_ _____

_ _____

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Hearing Problems

_ _____

_ _____

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Learning Disabilities

_ _____

_ _____

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Seizures/convulsions _ _____

_ _____

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Mental retardation

_ _____

_ _____

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Autism spectrum disorder _ _____

_ _____

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Prenatal and Birth History

Mother's general health during pregnancy (illnesses, accidents, medications, etc.):

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Length of Pregnancy: _ __________________________

Length of Labor: ____________________________

Birth Weight: ___________________________________

General Condition: _ _________________________

Type of delivery:

head first

feet first

breech

Caesarian

Were there any unusual conditions that may have affected the pregnancy or birth?

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Did the child experience any early feeding/swallowing problems (weak suck, turning "blue" while attempting to nurse, projectile vomiting, choking, lack of appetite, early fatigue, milk coming out nose while nursing, etc.)?

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Medical History Provide the approximate ages at which the child suffered the following illnesses and conditions: Asthma _______________________

Bronchitis_ ____________________

Chicken Pox _ _______________

Colds _ _________________________

Croup_ _________________________

Convulsions ________________

Dizziness _ ____________________

Draining ear __________________

Ear infections ______________

Encephalitis

_________________

German measles_ _____________

Headaches _ _________________

Head injury __________________

High fever

____________________

Influenza ___________________

Mastoiditis ___________________

Measles

_ ______________________

Meningitis __________________

Mumps _______________________

Pneumonia

_ __________________

Seizures ____________________

Sinusitis ______________________

Tinnitus

______________________

Tonsillitis _ __________________

Tuberculosis _________________

Vision problems _ _____________

Other _________________________________________________________________________________________________

Has the child had any surgeries?

If yes, what type and when (e.g., tonsillectomy, tube placement)?

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Describe any major accidents or hospitalizations?

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Does the child have any medical diagnoses? (e.g. ADD, autism, dyslexia)?

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Is the child taking any medications? If yes, identify:

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Have there been any negative reactions to medications? If yes, identify:

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Does you child have any known allergies? If yes, identify:

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Developmental History

Did your child:

Yes No

If no, at what age:

-- Hold his/her head up by 4 months

______

______

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-- First crawl by 12 months

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-- First walk alone by 16 months

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-- Become toilet trained by 3 years

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-- First grasped crayon/pencil

(thumb & finger) by 3 years

______

______

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