GENERAL CASE HISTORY

Date: _______________
Person completing this form:______________________

Relation:___________

I. CLIENT INFORMATION
_________________________________
PATIENT NAME (LAST, FIRST)

_________________

!MALE

!FEMALE

DATE OF BIRTH

_____________________________________________________________________________
STREET ADDRESS

CITY

______________________________________
HOME PHONE

STATE

ZIP CODE

____________________________________
E-MAIL ADDRESS

_____________________________________________________________________________
FATHERS/GUARDIANS NAME

WORK/CELL NUMBER

_____________________________________________________________________________
MOTHERS/GUARDIANS NAME

WORK/CELL NUMBER

_____________________________________________________________________________
REFERRING PHYSICIAN

TELEPHONE NUMBER

__________________________________________________________________________________________
PRIMARY PHYSICIAN
TELEPHONE NUMBER

II. INSURANCE INFORMATION

Do you have medical insurance? " YES " NO

________________________________________

____________________________

________________________________________

____________________________

_________________________________________

___________________________

POLICY HOLDER

INSURANCE PROVIDER

MEMBER ID NUMBER

DOB

INSURANCE COMPANY NUMBER

GROUP NUMBER

III. MEDICAL/DEVELOPMENTAL HISTORY

Complications during pregnancy:
Gestational Age:
Birth weight:
Reason for C-section:
Type of Delivery: " C- Section " Vaginal
Complications during/after Delivery: "Forceps "Vacuum Extraction " Jaundice " Required Oxygen
" Surgery " Sucking or swallowing problems " Other
Hospital Length of Stay:
Are immunizations up to date? " YES " NO
Known Allergies:____________________________________________________________________________
Medical Diagnosis:___________________________________________________________________________
List all medications and dosages currently prescribed for the patient (i.e., Amoxicillin, 1 tsp/2x daily):
__________________________________________________________________________________________
Please check the following as they apply to your child:
"Low birth weight "Hearing Loss " 3 or More Ear Infections " Wears Glasses "Seizure Disorder
"Surgeries:________________________________ "Hospitalizations:________________________________
When/where has his/her hearing been screened? Pass/Fail:

Concerns:

When/where has his/her eye-sight been screened? Pass/Fail:

Concerns:

Please list any other specialists that see the client:

Specialist Name

Area of Practice (Neurology, Psychologist)

Please list any special services the client received/currently receives:

Service (Speech Therapy, Special Education)
Dates Received

In your own words, please describe any developmental concerns you may have?
__________________________________________________________________________________________
_________________________________________________________________________________________
PHYSICAL/MOTOR DEVELOPMENT
Approximate age when child:
Rolled Over:
Sat Up Alone:
Crawled:
Walked:
Dress Self:
Tied Shoelaces:
Hand Preference: Right-handed?______ Left-handed?______
SPEECH AND ORAL MOTOR HISTORY
Does your child have any diagnosed speech or language delays, or do you have any concerns in this area?
__________________________________________________________________________________________________

Did your child begin:

Babbling/Cooing by age 4 months?
Respond to name/Peek-a-boo by 8 months
Imitating sounds/Using jargon by 12 months
Saying first words by 15 months
Saying 2 words together by 24 months
Using short sentences by 36 months

" YES " NO

" YES " NO
" YES " NO
" YES " NO
" YES " NO
" YES " NO

If no, age in months ________ " N/A

If no, age in months ________ " N/A
If no, age in months ________ " N/A
If no, age in months ________ " N/A
If no, age in months ________ " N/A
If no, age in months ________ " N/A

Indicate with a check mark any/all areas of difficulty:

"Being understood "Making requests "Understanding/Following Directions "Describing events

Are there any family members or relatives who have or have had speech, language, hearing, or motor problems?
" NO " YES If yes, who and what kind?________________________________________________________
SCHOOL HISTORY
What school does your child currently attend?______________________________________________________________
Grade:______________

Teacher:___________________________

Phone:________________________________

Describe your childs general progress and performance at

school:____________________________________________________________________________________________
Have teachers noted any areas of difficulty?
Please describe:______________________________________________________________________________________
How does your child get along with others at school?________________________________________________________
Does your child receive any supportive services currently or in the past (e.g. tutoring, speech therapy, counseling, other)?
Please describe:______________________________________________________________________________________
*Please provide a copy of an updated IEP/IFSP at the time of the evaluation.