Fillable Feeding Case History SPEECH/LANGUAGE CASE HISTORY

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Feeding Case History SPEECH/LANGUAGE CASE HISTORY

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  • 28 check-boxes
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1
THE SPEECH & HEARING CLINIC at
TEXAS WOMAN’S UNIVERSITY
Department of Communication Sciences & Disorders
P O Box 425737
Denton, TX 76204-5737
Phone: 940-898-2285 Fax: 940-898-2070
FEEDING CASE HISTORY
FOR CHILDREN
Please fill in the information as completely as possible.
I. BACKGROUND INFORMATION
Patient’s name: _____________________ Age: _____ Date of birth: ________ Sex: _____
Mother’s name: _____________________ Age: _____
Address: ______________________________________ Home phone: __________________
Street City State Zip
Mother’s occupation: ____________________________ Work phone: ___________________
Father’s name: ______________________ Age: _____
Address and phone: (if different than mother’s) _______________________________________
Street City State Zip Phone
Father’s occupation: _____________________________ Work phone: ___________________
Highest grade completed by mother: ________________ by father: _____________________
Are parents divorced? ______ If so, who has custody of child? _________________________
If child is not living with either biological or adoptive parent, who has legal guardianship?
_________________________________ Relation to child: ____________________________
Address: _______________________________________ Phone: ______________________
If the parent(s) are employed outside of the home, who cares for the child in their absence?
_____________________________________________________________________________
Family physician: ________________________ Phone: ______________________________
2
List siblings Age Sex Do they live in the home?
________________________________ _______ _______ _______________________
________________________________ _______ _______ _______________________
________________________________ _______ _______ _______________________
II. MEDICAL HISTORY
List medical diagnosis your child has been given: _____________________________________
_____________________________________________________________________________
List any surgeries or procedures your child has had performed: __________________________
_____________________________________________________________________________
List any medical tests your child has had and any important results (eg. MRI, UGI, VSS, MBS)
_____________________________________________________________________________
List any medications (prescription and over-the-counter) your child is taking: _______________
_____________________________________________________________________________
Check disease(s) your child has had, giving age and degree of severity:
Mild, average Mild, average
Disease Age or severe Disease Age or severe
allergies _____ __________ kidney disease _____ ____________
asthma _____ __________ measles _____ ____________
bronchitis _____ __________ meningitis _____ ____________
chicken pox _____ __________ mumps _____ ____________
colds (frequent) _____ __________ ear infections _____ ____________
hay fever _____ __________ pneumonia _____ ____________
headaches (frequent) _____ __________ scarlet fever _____ ____________
heart disease _____ __________ seizures _____ ____________
influenza _____ __________ tonsillitis _____ ____________
Other illnesses not noted above: __________________________________________________
Describe aftereffects of any illness, if any: __________________________________________
3
III. DEVELOPMENTAL HISTORY
During this pregnancy, did mother experience any unusual illness, condition or accident, such as
German Measles, false labor, RH incompatibility, etc? ________________________________
If so, describe: ________________________________________________________________
_____________________________________________________________________________
Length of pregnancy: __________ Duration of labor: __________ Birth weight: __________
Normal delivery: ______________ Caesarean: ________________ Breech birth: _________
Anesthetics: _______ Forceps: _______ Was infant blue? _______ Jaundiced? _________
Other concerns: _______________________________________________________________
Seizures? ____________ Swallowing or sucking difficulties? __________________________
_____________________________________________________________________________
Scars or bruises? ____________________ Was birth weight regained quickly? ____________
Drugs/Alcohol used during pregnancy? (type and amount) _____________________________
At what age did your child:
hold up his/her head alone? ________________________________
first crawl? _____________________________________________
sit alone without support? _________________________________
pull himself/herself to a standing position? ____________________
walk unaided? ___________________________________________
say his/her first word? ______________________________________
gain bowel control? ______ frequency of bowel movements ______ bladder control? _______
Weight of your child at 6 months: _______________ Weight at present: _________________
Is your doctor concerned about your child’s weight? yes no
Height at present? __________________ Does your child prefer right or left hand? ________
Describe your child’s speech: ____________________________________________________
4
Did you or do you have any concern about speech language development? yes no
If yes please
describe._____________________________________________________________________
_____________________________________________________________________________
Does your child seem to understand what is said to him/her? yes no sometimes
How can you tell? ______________________________________________________________
What language(s) are spoken in the home? __________________________________________
Which one is the primary language? _______________________________________________
IV. SENSORY
Does your child have
difficulty with balance?
fear of heights?
being moved unexpectedly?
Are there activities that involve fast movements and spinning that your child finds difficult? ___
_____________________________________________________________________________
Does your child seem awkward, uncoordinated? _____________________________________
Is your child sensitive to touch? loud noises?
If so, please describe.____________________________________________________
Does your child dislike any of the following?
bathing
walking barefoot clothing getting messy
Describe any developmental difficulties: ___________________________________________
_____________________________________________________________________________
Describe any academic difficulties: (reading, math, writing, spelling) _____________________
_____________________________________________________________________________
Does your child exhibit any sleep difficulties? If so, please describe: _____________________
_____________________________________________________________________________
5
V. FEEDING HISTORY
Does your child have a feeding tube? Ng Gtube G button
Amount and frequency of tube feeding? ____________________________________________
What kind of formula is used in the tube feeding? _____________________________________
Does your child eat by mouth? yes no
Amount and type of liquid taken:
by mouth ___________ breast ___________ supplemental nursing system_____________
Does your child use: a bottle? (nipple type) ______________ open cup ________________
straw _______________ spoon _________________________
sippy cup (free flow or no-spill; shape of spout) _____________________
How often? __________________________________________________________________
Do you add a thickening agent to the liquid? yes no
If so, what type? _____________________ how much? _______________________________
Which of the following food(s) does your child eat? puree crunchy snacks
finger foods soft chopped fruits/veggies
ground meat
most table foods
mixed consistencies (vegetable soup, spaghettios, etc…)
How often? ______________________ In what amounts? ____________________________
Does your child self-feed? yes no
Does
your child have difficulty chewing or swallowing? yes
no; If
so, please describe:
_____________________________________________________________________________
Does your child have difficulty eating foods with texture? yes no
If so, please describe: _______________________________________________________
What foods does your child prefer? ________________________________________________
List any food(s) that your child refuses to eat (if any)?__________________________________
Does your child exhibit any of the following during or after meals? cough/choke
wet gurgly voice quality wet breathing gagging arching
pulling or turning away eating/drinking a small amount then refusing any more crying
Has your child had a Modified Barium Swallow study? yes no
If so, when? __________ Results and recommendations?_________________________
_____________________________________________________________________________
Has your child had previous feeding therapy? yes no
6
If so, what was recommended?
____________________________________________________
Did you find it helpful? yes no
Describe a typical mealtime with your child: _________________________________________
_____________________________________________________________________________
What do you find most enjoyable? _________________________________________________
What do you find most frustrating? ________________________________________________
What are your goals for your child regarding feeding? _________________________________
_____________________________________________________________________________
VI. Social History
Describe how your child’s feeding issues affect your family: ___________________________
_____________________________________________________________________________
_____________________________________________________________________________ If there is any additional information about your child that would be helpful for us to know,
please list below.
____________________________________ ______________________________
Parent/Guardian signature Date
Thank you for your interest in our Speech Therapy Program at Texas Woman’s University.
If you have any questions, please call Kimberly Mory at (940) 898-2024. Please return this
case history to the following address or fax # to my attention.
Texas Woman’s University
Kimberly Mory
P O Box 425737
Denton, TX 76204-5737
Fax# (940) 898-2070
We look forward to hearing from you.
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Feeding Case History SPEECHLANGUAGE CASE HISTORY

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Completed 3 December 2019

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