Pediatric Speech and Language Case History FormStep 1 of 425%Identifying and Family InformationChild's Name First Last Child's Date of Birth MM slash DD slash YYYY Sex Male FemaleChild's Social Security NumberChild’s Race / Ethnicity Caucasian, Non-Hispanic Hispanic African-American Native American Asian or Pacific Islander OtherIf "Other", please enter below:Child's Primary LanguageOther Language(s) Spoken in the Home (and by whom)Does the Child Speak the Language(s)? Yes NoDoes the Child Understand the Language(s)? Yes NoReferred ByReason for ReferralChild's Primary Care Physician (PCP)PCP Phone NumberPCP Fax NumberMother's NameMother's CellMother's Work PhoneMother's Email Mother's AddressMother's Date of BirthMother's OccupationFather's NameFather's Cell PhoneFather's Work PhoneFather's Email Father's AddressFather's Date of BirthFather's OccupationChild Lives With (check one of the following) Birth Parents Foster Parents One Parent - Mother One Parent - Father Adoptive Parents Parent (Mother) and Step Parent Parent (Father) and Step Parent OtherWhen was your child's most recent hearing evaluation/screening? MM slash DD slash YYYY What were the results?When was your child's most recent vision evaluation/screening? MM slash DD slash YYYY What were the results?Describe your concerns regarding your child’s speech and language skills:When did you first become concerned?Does your child present with any current medical and/or communication diagnoses? Yes NoIf yes, please describe (with date(s) of onset, if possible)Other Children in the Family (Name) Add Remove(Age) Add Remove(Sex) Add RemoveHas your child previously received a speech and language evaluation/screening? Yes NoIf yes, where and when? What were the results?Has your child previously received speech therapy services? Yes NoIf yes, where and when?Who was your child’s Speech-Language Pathologist?What were the treatment goals?Has your child previously received any other therapy services (i.e., physical therapy, occupational therapy, counseling, vision, behavioral, etc.)? Yes NoIf yes, please describe:Have any of the child’s immediate family members been diagnosed with any of the following? Please indicate “F” for child’s father, “M” for child’s mother, “S” for child’s sibling, “MGF” for child’s maternal grandfather, “MGM” for child’s maternal grandmother, “PGF” for child’s paternal grandfather, and “PGM” for child’s paternal grandmother:Learning DisabilityDyslexiaSensory Processing DisorderAuditory Processing DisorderADD/ADHDAutism/PDD/otherSpeech and Language Delay/DisorderFluency Disorder (i.e. Stuttering)Describe your personal goals for your child’s speech therapy processDescribe any other concerns regarding your child’s developmentDoes your child present with an awareness or frustration toward his or her speech and language deficits?Speech, Language, and Hearing Development:When did your child begin to “coo” or “babble?”When did your child produce his or her first word?What was your child’s first word?When did your child begin to use 2-3 word phrases?Did your child ever appear to “stop talking” or present with a regression in speech/language skills? Yes NoIf yes, please describeApproximately how many words does your child verbalize without assistance? 1-5 6-10 10-15 15-25 25-50 Over 50How does your child communicate his or her needs and intentions? Via gestures (e.g. pointing) Single words Phrases SentencesDoes your child produce any sounds incorrectly (e.g. articulation concerns)? Yes NoIf yes, please describeDoes your child hesitate, “get stuck,” repeat, or stutter on sounds or words? Yes NoIf yes, please describeWhen did you first notice this behavior?Can your child tell a simple story? Yes NoHow well can your child be understood by familiar individuals (indicate “A” for all the time; “M” for most of the time; “S” for some of the time; or “R” for rarely)?How well can your child be understood by unfamiliar individuals (indicate “A” for all the time; “M” for most of the time; “S” for some of the time; or “R” for rarely)?Does your child present with appropriate eye contact when speaking with individuals? Yes NoDoes your child consistently respond to his or her name? Yes NoDoes your child appear to understand what is communicated to him or her? Yes NoIs your child able to follow simple directions? Yes NoPlease provide specific examples:Birth HistoryDid the child’s mother present with any medical complications during the pregnancy? Yes NoIf yes, please describe (as well as any medical attention received):Did the child’s mother consume any prescription and/or nonprescription medication during pregnancy? Yes NoIf yes, please describe:Was the child considered full-term? Yes NoIf no, what was the gestational age?What type of delivery was present? Vaginal Cesarean SectionHow long did the child remain in the hospital prior to being discharged?Feeding/Swallowing/Oral Motor HistoryWas the child breast-fed or bottle-fed? Breast-fed Bottle-fedIf breast-fed, for how long?Do you have any past/present concerns regarding the child’s feeding, swallowing, and/or oral motor skills?What age did your child begin:Puree Foods(e.g. rice cereal, Stage I jarred food)Soft ChewablesTable FoodIs your child a “picky eater?” Yes NoList any foods that the child once ate and has since stopped eating: Add RemovePlease list the child’s preferred foods: Add RemoveDid the child previously present with difficulty transitioning to different food textures? Yes NoIf yes, please describeChild currently consumes food/drinks via (check all that apply) Finger foods Uses fork Uses spoon Drinks from open cup Uses strawDoes the child currently suck his or her thumb/fingers and/or place objects in the oral cavity? Yes NoIf yes, please describePlease describe when the following first occurred:Sat upCrawledStoodWalkedRanBladder trainedBowel trainedWhich hand does the child use more frequently? Right Left No preferenceDoes your child present with any allergen complications? Yes NoIf yes, please describeDoes your child currently take any medication? Yes NoIf yes, please describe (with name of medication and dosage)Does your child present with a history of the following? (please select all that apply):Select all that apply adenoidectomy encephalitis adenoidectomy seizures flu sinusitis breathing difficultiesSelect all that apply head injury sleeping difficulties chicken pox high fevers colds measles tonsillectomySelect all that apply ear infections meningitis tonsillitis mumps vision problems ear tubes scarlet feverDescribe any other illnesses, accidents, surgical procedures, injuries, and hospitalizations of the child?Child prefers to primarily play Alone With older children With younger children With adultsIs your child sensitive to loud sounds? Yes NoBright lights? Yes NoDoes your child do the following? Ignores environmental sounds. Localizes (locates) the source of sound Requires verbal repetition of information Responds consistently to sound Listens selectively in the presence of noise.Please describe your child’s behavioral characteristics (check all that apply):Select all that apply cooperative motivated to complete tasks restless attentive poor eye contact willing to try new activities easily distracted/short attention plays alone for reasonable length of timeSelect all that apply destructive/aggressive separation difficulties withdrawn easily frustrated/impulsive inappropriate behavior stubborn self-abusive behaviorEducational InformationWhat school/daycare does the child currently attend?GradeAddress of schoolHas your child ever been retained in school? Yes NoIf yes, please describeHas the child ever received therapy services through his or her enrolled school district? Yes NoIf yes, please describeWhat are your child’s strengths and/or best subjects in school?What are your child’s weaknesses and/or most difficult subjects in school?Has your child been seen by any other medical professionals, other than his or her PCP? Yes NoIf yes, please describeEmergency Contact InformationNameRelationship to ChildTelephone NumberCell NumberName of Individual Who Completed This FormRelationship to ChildEmail AddressDate MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
