Speech-Language-Hearing Case History Questionnaire Child Lives With: Birth Parents Mother Adoptive Parents

Foster Parents Father Parent and Step-parent

Other

Does child have siblings? ______ Yes ______ No If yes, how many? _______________________________________________________

Family History of Speech and Language Diagnoses: ______ Yes ______No If yes, please explain: _____________________________________________________

Child’s race/ethnic group: Caucasian Native American

Hispanic Asian

African-American Other

Birth History How old was the mother when the child was born? How many months was the pregnancy? Were there any complications that occurred either during the pregnancy or the birth process? Yes No If yes, please describe. ___________ ______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Did the child go home with his/her mother from the hospital? Yes If child stayed at the hospital, please describe why and how long.

No

____________________________________________________________________________ ____________________________________________________________________________

1

Speech-Language-Hearing Case History Questionnaire Medical History Does your child have any known medical diagnosis?

Does your child have any known allergies? ____ Yes ______ No ___________________ Seasonal _________________________ Food ___________________ Latex _________________________ Dye ___________________ Medication _________________________ Other

Does your child have any dietary restrictions: ____ Yes _____ No If yes, please explain: ____________________________________________________________________________ ____________________________________________________________________________

Has your child had any of the following? Adenoidectomy Asthma Measles Tonsillitis Esophageal Reflux ______Mumps Tonsillectomy ______Vocal nodules/polyps ______Chicken Pox Frequent colds Seizures Encephalitis Sinusitis Head Injury Flu Ear infections High Fever Vision problems Ear tubes Scarlet Fever Sleeping difficulties Breathing Difficulties Meningitis Xerostomia (Dry Mouth)

Other medical condition(s): Other serious injury/surgery: Is your child currently (or recently) under a physician’s or specialist’s care? ____Yes ____No If yes, why?

Please list any medications your child takes regularly:

Has your child been or is he/she currently under the care of an orthodontist? ____Yes _____No If yes, Please explain ____________________________________________________________________________

2

Speech-Language-Hearing Case History Questionnaire Developmental History Please tell the approximate age that your child achieved the following developmental milestones: _____Sat up _____Crawled _____Stood _____Walked _____Babbled

_____Used Single Words _____Combined Words _____Fed Self _____Dressed Self _____Toileted

Behavioral Characteristics Cooperative Willing to try new activities Separation difficulties Stubborn Poor eye contact Destructive/aggressive Inappropriate behavior

Attentive Plays alone for reasonable length of time Easily frustrated/impulsive Restless Easily distracted/short attention Withdrawn Self-abusive behavior

Please list specific toys or activities that motivate your child: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Hearing Did the child pass his/her newborn hearing screen?

______ Yes ______No

Do you feel your child has a hearing problem? ______ Yes ______No If so, please describe: _________________________________________________ _________________________________________________________________________ Has he/she ever had a hearing evaluation/screening? ______ Yes ______No If yes, where and when? _______________________________________________ What were you told? _____________________________________________________ ____________________________________________________________________________

3

Speech-Language-Hearing Case History Questionnaire Oral Motor/Feeding Please tell the approximate age that your child achieved the following feeding milestones: _______ Drank from a sippy cup ______Consumed mashable table foods ______Drank from an open cup _________Consumed a variety of food textures ______Consumed solids Does your child currently… Use a pacifier? ______ Choke on food or liquids? Put toys, objects or clothing in his/her mouth? Brush his/her teeth and/or allow brushing? ______ Hold food in his/her mouth? ______ Sleep with mouth open, or is his/her mouth open at rest? ______ Snore? ______ Drool? ______ Eat in a messy manner? ______ Have difficulty with use of a straw or bottle? ______ Suck his/her thumb? Is he/she a picky eater? ____ Yes _____ No If so, please explain: ____________________________________________________________________________ ____________________________________________________________________________

Speech and Language Does your child currently… 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 Respond correctly to yes/no questions? Respond correctly to who/what/where/when/why questions? ______Ask questions of others? ______Communicate his or her basic wants, needs, and feelings? ______Comment on daily activities, objects, and people within his or her environment? ______Participate in conversations with others? Please check below any/all forms your child currently uses to communicate: Body language __ Sounds (vowels, grunting) Words (shoe, doggy, up) 2 to 4 word sentences Sentences longer than four words Other

4

Speech-Language-Hearing Case History Questionnaire Do you feel your child has a speech/language problem? If yes, please describe.

Yes

No

Has he/she ever had a speech and language evaluation/screening? If yes, where and when? What were you told?

Yes

No

Has he/she ever had speech/language therapy? If yes, where and when? What were you told?

Yes

No

Is your child aware of, or frustrated by, any speech/language difficulties? Do you feel your child’s speech and/or language difficulties are impacting his/her social interactions with peers and/or adults? ______ Yes ______No If yes, please explain: ____________________________________________________ ____________________________________________________________________________

Additional Information Has your child received any other evaluation or therapy? (physical therapy, occupational therapy, etc.) Yes No If yes, where and when? What were you told?

What do you see as your child’s most difficult problem at home? What do you see as your child’s most difficult problem at school?

What are you hoping your child will achieve through outpatient speech/language therapy? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

5

Speech-Language-Hearing Case History Questionnaire School History If your child is school-age, please answer the following: Name of school and child’s grade level: What are your child’s strengths and/or best subjects?

Is your child having difficulty with any subjects?

Is your child receiving any special services through his/her school? __ If yes, please describe.

Yes

No

Has your child ever completed psycho-educational testing through the school system? Yes No If yes, please describe.

Do you have any additional documentation to provide for us today? Yes No If yes, please describe or attach. ______________________________________________________________________

6