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

The  George  Washington  University  Speech  &  Hearing  Center   Speech  Therapy  Child  Case  History  Form       General  Information   Child’s ...
Author: Loraine Small
4 downloads 0 Views 79KB Size
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):    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       What  languages  does  the  child  speak?    What  is  the  child’s  primary  language?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________        

What  languages  are  spoken  in  the  home?    What  is  the  dominant  language  spoken?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       With  whom  does  the  child  spend  most  of  his  or  her  time?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Describe  the  child’s  speech-­‐language  problem  (e.g.  voice,  stuttering,  expressive/receptive   language  delay,  articulation,  reading  difficulty,  etc.).    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________     How  does  the  child  usually  communicate  (gestures,  single  words,  short  phrases,   sentences)?    Please  give  examples.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       When  was  the  problem  first  noticed?    By  whom?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      

What  do  you  think  may  have  caused  the  problem?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Has  the  problem  changed  since  it  was  first  noticed?    If  yes,  explain.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Is  the  child  aware  of  the  problem?  If  yes,  how  does  he/she  feel  about  it?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Have  any  other  speech-­‐language  specialists  seen  the  child?    Who  and  when?    What  were   their  conclusions  or  suggestions?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       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.      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________    

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  

 ______      ______    

 _______________________________________________    

Hearing  Problems  

 ______      ______    

 _______________________________________________    

Learning  Disabilities  

 ______      ______    

 _______________________________________________    

Seizures/convulsions  

 ______      ______    

 _______________________________________________    

Mental  retardation  

 ______      ______    

 _______________________________________________    

Autism  spectrum  disorder    ______      ______    

 _______________________________________________    

  Prenatal  and  Birth  History   Mother’s  general  health  during  pregnancy  (illnesses,  accidents,  medications,  etc.):    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       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?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________            

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.)?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       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)?      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      

Describe  any  major  accidents  or  hospitalizations?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Does  the  child  have  any  medical  diagnoses?  (e.g.  ADD,  autism,  dyslexia)?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Is  the  child  taking  any  medications?  If  yes,  identify:    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Have  there  been  any  negative  reactions  to  medications?  If  yes,  identify:    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Does  you  child  have  any  known  allergies?  If  yes,  identify:    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Developmental  History   Did  your  child:   Yes     -­‐  Hold  his/her  head  up  by  4  months    ______    

No  

If  no,  at  what  age:  

  ______      _______________________________________    

-­‐  First  crawl  by  12  months  

 ______    

  ______      _______________________________________    

-­‐  First  walk  alone  by  16  months  

 ______    

  ______      _______________________________________    

-­‐  Become  toilet  trained  by  3  years  

 ______    

  ______      _______________________________________    

-­‐  First  grasped  crayon/pencil          (thumb  &  finger)  by  3  years  

 ______    

  ______      _______________________________________    

Did  your  child:    

Yes  

No  

If  no,  at  what  age:  

-­‐  First  sit  alone  by  12  months  

 ______    

  ______      _______________________________________    

-­‐  First  ate  solid  food  by  12  months  

 ______    

  ______      _______________________________________    

-­‐  Feed  self  by  2  years  

 ______    

  ______      _______________________________________    

-­‐  First  use  scissors  by  3  years  

 ______    

  ______      _______________________________________    

-­‐  Cry  normally  to  communicate          pain,  fear,  discomfort,  loneliness  

 ______    

  ______      _______________________________________    

-­‐  Cooing/babbling  by  4  months  

 ______    

  ______      _______________________________________    

-­‐  Respond  to  name/peek-­‐a-­‐boo          by  8  months  

 ______    

  ______      _______________________________________    

-­‐  Use  jargon*  by  12  months  

 ______    

  ______      _______________________________________    

-­‐  Imitate  sounds  by  12  months  

 ______    

  ______      _______________________________________    

-­‐  Say  first  word  by  15  months  

 ______    

  ______      _______________________________________    

-­‐  Say  2  words  together  by  24  months    ______    

  ______      _______________________________________    

-­‐  Use  short  sentences  by  36  months    ______    

  ______      _______________________________________    

*Jargon  is  defined  as  words  that  are  not  understandable,  but  are  said  in  “sentences”  where  the  child’s   inflections  let  you  know  that  he  is  “saying  something.”  

  Are  there  or  have  there  ever  been  any  feeding  problems  (e.g.  problems  with  sucking,   swallowing,  drooling,  chewing)?    If  yes,  describe.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Please  describe  your  child’s  gross  motor  skills  (coordinated,  clumsy,  falls  a  lot,  slow,  etc.)   while  walking,  running,  climbing,  riding  bikes,  roller  skating,  etc.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________    

Please  describe  your  child’s  fine  motor  skills  while  attempting  to  color,  write,  draw,  cut   with  scissors,  feed  him/herself  with  utensils,  etc.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Describe  the  child’s  response  to  sound  (e.g.  responds  to  all  sounds,  responds  to  loud   sounds  only,  inconsistently  responds  to  sounds,  etc.).    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Has  your  child’s  hearing  been  tested  previously?    If  yes,  when  and  what  were  the  results?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       Indicate  with  a  checkmark  any  items  that  are  difficult  for  your  child?      Eating  a  variety  of  foods    

   Understanding  what  he/she  hears  

   Following  directions  or  routines    

   Speaking  in  organized  or  grammatically    

 

 

 

   Answering  questions    

correct  sentences  

   Pronouncing  words  correctly  

   Singing  songs/reciting  nursery  rhymes        Stating  sounds  of  letters      Recognizing  “common”  words    

   Writing  his/her  name  

   Rhyming    

   Getting  his/her  point  across  

   Thinking  of  words  for  things    

   Understanding  concept  of  time  (seasons,    

 

 

 

day/night,  hours)  

   Telling  stories    

   Self-­‐calming  

   Receiving/giving  hugs    

   Keeping  shoes  on  

   Eye-­‐Hand  coordination    

   Using  a  straw  

   Blowing  bubbles    

   Keeping  hands  to  him/herself  

Behavioral  History   Please  check  all  that  describe  your  child:        Friendly    

   Separation  difficulties  

   Attentive  

   Impulsive/impatient    

   Poor  memory  

   Clumsy  

   Easy-­‐going    

   Cooperative    

   Has  temper  tantrums  

   Sleeps  well  

   Difficulty  sleeping    

   Has  nightmares    

   Hyperactive    

   Doesn’t  like  to  be  read  to  

   Bites  nails  

   Defiant  

   Unpredictable  

   Bad  tempered  

   Aggressive/destructive    

   Willing  to  try  new  activities  

   Talkative  

   Stubborn  

   Will  not  eat  certain  textures  

   Cries  easily  

   Poor  eye  contact  

    Eats  well  

   Grinds  teeth  

   Wets  bed  

   Easily  frustrated  

   Withdrawn  

   Mouth  breather  

   Restless  

   Shy  

   Snores  

   Quiet  

   Daydreams  often  

  Sensitive  to  sounds  

   Overly  sensitive    

   Plays  well  with  other  children      

 

emotionally  

   Cannot  easily  shift  from  one  activity  to  another  

   Doesn’t  like  to  be    

   Still  uses  pacifier/sucks  thumb      

 

touched  

   Plays  alone  for  reasonable  amount  of  time      Will  not  touch  certain  textures      Distractive/short  attention  span       Educational  History   School:  ____________________________________________________    

Grade:    _______________________________    

Teacher(s):  ___________________________________________________________________________________________       How  is  the  child  doing  academically  (or  pre-­‐academically)?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________    

Does  the  child  receive  special  services?  If  yes,  describe.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       How  does  the  child  interact  with  others  (e.g.  shy,  aggressive,  uncooperative,  etc.)?    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________       If  enrolled  for  special  education  services,  has  an  Individualized  Educational  Plan  (IEP)  been   developed?  If  yes,  describe  the  most  important  goals.    ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________      ________________________________________________________________________________________________________    

Suggest Documents