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. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________