Fillable 7.16.15 Rev. 2 Child Case History California State University, Fresno

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7.16.15 Rev. 2 Child Case History California State University, Fresno

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Revised 7.15.15
California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive M/S PH 80
Fresno, California 93740-8019
(559) 278-2422 Fax (559) 278-5187
CHILD CASE HISTORY
PLEASE PRINT IN INK OR TYPE ALL INFORMATION
General Information: Today’s Date: _________________
DiagnosticPlease Check One: Hearing Evaluation Individual Speech Therapy
PUPS Preschool SEALS Preschool STARS Preschool
Child’s Name: ________________________________ Date of Birth:
____________ Gender: __________
Address
: __________________________________ City:
____________________ Zip: _________________
Mother’s Name: __________________________________________
Age:__________________________
Mother’s Occupation: ______________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Father’s Name: ___________________________________________
Age:__________________________
Father’s Occupation: ______________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Does the child live with both parents? _________________________________________________________
Emergency Contact Name: _________________________________
If no, with whom does the child live? __________________________________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Referred By: __________________________________________
Phone:___________________________
Physician: _____________________________________________
Phone:___________________________
Address: __________________________________________________________________________________
Office Use Only:
Date Received: ____________________________________________________________________________
Dates Contacted: ___________________________________________________________________________
Relationship: __________________
Brothers and Sisters (include names and ages): ___________________________________________________
Email:__________________________
Email:
__________________________
Revised 7.15.15
Other specialists who have seen the child: ______________________________________________________
Please provide copies the most recent report for the Doctor, agency or school listed above.
Address: _________________________________________________ Phone:________________________
What were the other specialists’ conclusions and/or recommendations? _____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What language (s) does the child speak? _______________________________________________________
How does the child usually communicate?
Gestures Sign Language Single Words Short Phrases Sentences
Describe the child’s speech-language or hearing problem. _________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
When was the problem first noticed? __________________________________________________________
Who first noticed the problem? _______________________________________________________________
What do you think may have caused the problem? _______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Since you first noticed the problem, what changes have you observed in your child’s speech, language, or
hearing? __________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Revised 7.15.15
Is the child aware of the problem? ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What have you done to help your child with the problem? ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe other speech, language, or hearing problems in the family. ________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prenatal and Birth History:
Describe mother’s general health during pregnancy (illnesses, accidents, prescription and non-
prescription medications, etc.). _______________________________________________________________
__________________________________________________________________________________________
Length of pregnancy: ________________________ Length of labor: _____________________________
Child’s general condition: ____________________ Birth weight: ________________________________
Circle type of delivery: Head First Feet First Breech Cesarean
Were forceps used? _________________________
Child’s length of stay in hospital: ____________________________
Describe any unusual conditions that may have affected the pregnancy or birth. ______________________
__________________________________________________________________________________________
Revised 7.15.15
Medical History:
Child’s general health is: Good Fair Poor
Provide the approximate ages at which the child experienced the following illnesses and conditions.
Adenoidectomy ____________ Asthma __________________ Allergies ____________________
Chicken pox _______________ Colds ___________________ Convulsions _________________
Croup ____________________ Draining ear _____________ Dizziness ___________________
Ear infections ______________ Epilepsy _________________ Encephalitis _________________
German measles ___________ Headaches _______________ Hearing loss _________________
Heart problems ____________ High fever _______________ Influenza ___________________
Measles ___________________ Mastoiditis _______________ Meningitis __________________
Mumps ___________________ Noise Exposure ___________ Pneumonia __________________
Seizures __________________ Sinusitis _________________ Tinnitus ____________________
Tonsillitis _________________ Tonsillectomy ____________ Visual Problems _____________
Other ____________________ Glasses __________________
List child’s current medications. ______________________________________________________________
__________________________________________________________________________________________
Describe any major accidents, surgeries, or hospitalizations the child has had. _______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Revised 7.15.15
Developmental History
Write the approximate age when the child began to do the following.
Crawl _______ Sit __________ Stand _________ Walk ________ Feed Self _____________
Dress Self _________ Use toilet ________ Use single words ________ Combine words _______________
Name simple objects ________ Use simple questions ________ Engage in a conversation ___________
Does the child have any motor difficulty, such as walking, running, or participating in other activities
which require small or large muscle coordination? ______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing, etc.) your
child has had. ______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does the child:
Respond to any sounds? __________
Respond to the sound of the telephone bell? ________
Respond to the sound of human voices? _________
Respond to loud sounds only? __________
Respond to sounds inconsistently? ___________
Seem to ignore sounds willfully? ___________
Do you suspect any problems with hearing?
Revised 7.15.15
General Behavior
Does the child eat well? _______________ Sleep well? ______________
How does the child interact with other family members? ___________________________________
____________________________________________________________________________________
Is the child: Attentive Extremely Active Restless
Does the child bang his/her head, rock, or spin? ________________
Does the child play by him/herself? __________
How does the child interact with other children? _________
Does the child lose his/her temper? __________
With whom does the child spend most of the day? __________
Educational History
School or Preschool: ____________________________________ Grade: __________________________
Teacher (s): _______________________________________________________________________________
Describe any special services your child receives. ________________________________________________
__________________________________________________________________________________________
If enrolled for special education services, list main goals of the Individualized Educational Plan (IEP) or
Individual Family Service Plan (IFSP). ________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Revised 7.15.15
Please add any additional information you feel might be helpful in the evaluation or treatment of the
child’s problem. ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PLEASE ATTACH ANY REPORT YOU HAVE FROM ANOTHER AGENCY, SCHOOL OR DOCTOR.
Person completing the form: _________________________________________________________________
Relationship to the child: ____________________________________________________________________
Signed: _______________________________________________ Date: ____________________________
***Please Note: You must complete and sign the attached Observation and Photo Consent statements and return them
with your case history form. Thank you for taking the time to fill out the forms completely and accurately.
Revised 7.15.15
California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive M/S PH 80
Fresno, CA 93740-8019
(559) 278-2422 Fax (559) 278-5187
Observation Consent
Consent is hereby given to faculty, students and other persons approved by the clinical supervisor at the
Language, Speech and Hearing Clinic at California State University, Fresno to observe
_________________________________ in the clinic or in off campus settings.
The purpose of these observations is to train University Communicative Sciences & Disorders students
(both diagnostic and treatment sessions may be observed). Students from other departments studying
children and adults with language, hearing, and speech disorders may also watch and listen if the
supervisor gives permission.
__________________________________________ ______________________________
Parent/Guardian/Self (18 or older) Date
Client Name
Revised 7.15.15
California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive M/S PH 80
Fresno, California 93740-8019
(559) 278-2422 (559) 278-5187 fax
Consent and Release for Photographs or Videotaping
Consent is hereby given to the Speech, Language, & Hearing Clinic, at California State
University, Fresno, to take photographs, or videotape of _______________________________. I
understand that the photos/videos will be used to train University students and demonstrate department
activities to the general public (e.g. CDDS department website or on Professional Health Services
building bulletin boards).
I understand that I will be able to view the photographs or videotape if I request to do so.
_______________________________________ _______________________
Parent/Guardian/Self (18 or older) – Print Name Date
_______________________________________
Signature
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7.16.15 Rev. 2 Child Case History California State University, Fresno

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Completed 22 May 2020

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