Fillable CHILD-CASE-HISTORY Speech-Language-Audiology Case History for Children

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CHILD-CASE-HISTORY Speech-Language-Audiology Case History for Children

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SPEECH-LANGUAGE-AUDIOLOGY
CASE HISTORY
FOR CHILDREN
In preparation for your child’s hearing and/or speech evaluation/therapy, we would like you to
provide us with the following information. This information will assist the clinic staff in planning for
and conducting a more meaningful examination and/or therapy session. Please return this completed
form as soon as possible so an appointment time can be finalized for your child.
Please answer the questions as fully and accurately as possible. Many parents have found the child’s
baby book helpful in remembering particular dates. If you are not sure of a particular date, write the
date that you think is correct and put a question mark after it. Your family physician may also be able
to provide you with some information.
All of the following information is for the
confidential
use of the Speech, Language and Hearing
Clinic staff only.
Date:
Person completing this form: ____________________
Name Relationship to child
I.
REFERRAL
Who referred your child to this clinic?
Professional title and/or relationship to the child:
Address:
Street City State Zip
Phone Number:
Which of the following evaluation(s)/and/or therapy are you interested in?
Audiology Evaluation Speech/Language Evaluation
Both Evaluations Speech Therapy
What are your concerns in the areas of hearing, speech and language?
Page 2 of 9
II.
Child’s Name:
Age:
Date of Birth: Male Female
Address:
Street
Phone:
City State Zip Code
Mother’s Name:
Age:
Address:
Street
Home Phone:
Cell Phone:
City State Zip
Email Address:
Mother’s Occupation: Work Phone:
Father’s Name: Age:
Address:
Street
Home Phone:
Cell Phone:
City State Zip
Email Address:
Father’s Occupation: Work Phone:
Highest grade level completed by mother: By father:
Are parents divorced? Yes No If yes, who has custody of the child?
If child isn’t living with either biological or adoptive parent, who has legal guardianship?
Relationship to child:
Address:
Street
Home Phone:
Cell Phone:
City State Zip
If the parent(s) are employed outside the home, who cares for the child in their absence?
Family physician: Phone:
Page 3 of 9
List Siblings Age Male/Female Do they live in the home?
Yes
No
Yes No
Yes No
Yes No
Does anyone in the family have speech or hearing problems?
Yes No
If yes, indicate the relationship to the child and explain the type of problem:
III.
BIRTH AND PRENATAL HISTORY
During this pregnancy, did mother experience any unusual illness, condition or accident, such as
German Measles, false labor, RH incompatibility, etc.? Yes No If yes, please
describe:
Length of pregnancy: Duration of labor: Birth weight:
Condition at birth: Normal delivery Caesarean Breech birth
Anesthetics: Yes No Forceps: Yes No Was infant blue? Yes No
Jaundiced: Yes No Other unusual conditions?
Conditions immediately following birth:
Did infant have: Feeding problems Scars or bruises Seizures
Swallowing or sucking difficulties Was birth weight regained quickly: Yes No
Other (please explain)
IV.
DEVELOPMENT
First hold head up alone with no assistance? First crawl?
Sit alone without support?
Pull himself/herself up to a standing position? Walk unaided?
Gain bowel control? Bladder control?
Weight of your child at 6 months? Present weight? __________
Page 4 of 9
Present height? Does your child prefer right or left hand?
Does your child fall or lose balance easily? Yes No If yes, please explain:
Does your child have (check all that apply): Difficulty with balance? Fear of heights?
Show fear if moved unexpectedly?
Are there activities that involve fast movements and spinning that your child finds difficult? Please
explain
Does your child like to go to Six Flags? Yes No
Can your child ride a bike? Yes No
Does your child seem awkward or uncoordinated? Yes No
Does your child have difficulty chewing or swallowing? Yes No
Describe any developmental difficulties?
Describe any academic difficulties: (reading, math, writing, spelling)
Additional comments:
V.
MEDICAL
Check disease(s) your child has had, giving age and degree of severity:
Disease
√
Age
Mild, Average, or
Sever
e
Disease
√
Age Mild, Average, or
Severe
Allergies Kidney Disease
Asthma Measles
Bronchitis Meningitis
Chicken Pox Mumps
Colds (frequent) Ear Infection
Hay fever Pneumonia
Headache
(frequent)
Scarlet Fever
Heart Disease Seizures
Influenza Tonsillitis
Page 5 of 9
What are your child’s usual grades? (Check one)
Excellent Above average Average Below average
Failing
What is your child’s attitude toward:
School?
His/hers homework?
How does your child get along with others at school?
Does your child sleep well? Yes No Does your child eat well? Yes No
VI.
SOCIAL
What activities and games does your child enjoy?
Does your child tend to play alone or with other children?
What are the ages of your child’s playmates?
Does he/she show fear? Often Sometimes Rarely
What does he/she fear?
Is he/she “nervous”? Yes No
How does he/she show it?
Has he/she been harder to manage than other children? Yes No
By whom and how is your child disciplined?
Is your child difficult to discipline? Yes No Explain:
______________________________________________________________________________________________
Please check the boxes which identify your child’s behaviors:
lying sluggishness tongue sucking
begging boastfulness strong fears
stealing showing off strong hates
smoking disobedience shyness
rudeness destructiveness worrying
swearing temper displays sensitivity
fighting acts of violence easily depressed
Page 6 of 9
jealousness quarrelsome behavior easily discouraged
selfishness day-dreaming suicidal inclinations
excitability thumb sucking running away from home
skipping school nail biting associate w/bad company
nose picking sex misbehavior prefers younger children
sleeplessness convulsive behavior prefers older children
nightmares sleepwalking snoring
constipation fainting bed wetting
mouth breathing face twitching complains of pain
night terrors
Are there any indications of your child not hearing plainly? Yes No
Discuss any of the above items in more detail if you think they would shed light on the problem:
____________________________________________________________________________
____________________________________________________________________________
VII.
SPEECH AND HEARING HISTORY
During your child’s first 6 months, did he/she coo and babble? Yes No
During the first year, did he/she make many sounds other than crying? Yes No
Other than crying, would you say your child was:
A silent baby? An average baby? A very noisy baby?
At what age did your child first day meaningful words?
What were they?
Did your child: say one or two words then go for a long time before saying other words?
Or continuously add words once he/she started to talk?
At what age did your child begin to name people and objects?
At what age did your child have a name for everything?
At what age did your child combine words into small sentences like, “want drink” or “me out”?
At what age did your child combine short sentences?
Do you think your child has been slow in learning to talk? Yes No
Does your child understand what you say as well as you think he/she should? Yes No
If no, please explain:
Page 7 of 9
Does your child verbalize now? Yes No if no, how does he/she make requests?
At this time does your child talk:
a great deal? an average amount? very little?
Does your child’s talking consist mainly of:
complete sentences? phrases? one or two words? sounds?
How well can your child be understood by brothers, sisters, playmates?
good sometimes not at all
Comments:
How well can your child be understood by adults other than family members?
good sometimes not at all
Comments:
Did speech learning ever seem to stop for a period? Yes No
If “yes”, please describe:
Has your child ever communicated better than they do now? Yes No
If “yes”, please explain:
___________________________________________________________________________
XI. OTHER INFORMATION
If you suspect that your child has a hearing problem, when, why and by whom was the
hearing problem first noticed?
Is your child teased about his/her speech problem by others? Yes No
If “yes”, please explain:
________________________________________________________________________________
Page 8 of 9
What is your child’s reaction to his/her speech problem? ____________________________
Has your child had a hearing examination prior to this time? Yes No
If “yes”, when?
Where?
Has your child had a neurological examination prior to this time? Yes No
If
“yes”, when?
Where?
Has your child had a psychological examination prior to this time? Yes No
If “yes”, when?
Where?
Has your child had an educational examination prior to this time? Yes No
If “yes”, when
Where?
Has your child had a recent medical examination? Yes No
If “yes”, when?
And by whom?
If your child has had any of the above examinations, it will be helpful to the clinic if you
contact the person who examined your child and ask them to send a copy of their findings to
the address at the bottom of this page or fax it to 940-898-2276. If there is any additional
information which you feel will help us to understand your child better, please describe:
Signature Date
click to sign
signature
click to edit
Page 9 of 9
Please complete the additional authorization forms that are attached. Once we have received this
packet in our office, you will be contacted to schedule an evaluation.
If you have any questions, please contact the clinic at (940) 898-2285. You may mail this packet to
the address below or e-mail to mzamoracalderon@twu.edu. You may also fax to (940) 898-2276.
Mail to:
Texas Woman's University
Speech, Language and Hearing Clinic – MCL 601
P.O. Box 425737
Denton, Texas 76204
Attn: Marisa
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CHILD-CASE-HISTORY Speech-Language-Audiology Case History for Children

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Completed 4 December 2019

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