CASE HISTORY

Identifying and Family Information:

Patient’s Name:___________________ Birthdate:____________ Sex: M F
Address:________________________ Cell Phone:________________________
_________________________ Telephone:_________________________
_________________________ E-mail:____________________________

Father’s Name:___________________ Cell Phone:________________________

Address:________________________ Telephone:________________________
_________________________ E-mail:___________________________
_________________________

Mother’s Name:__________________ Cell Phone:________________________

Address:________________________ Telephone:_________________________
_________________________ E-mail:___________________________
_________________________

Patient lives with (check one):

Birth Parents Foster Parents One Parent
Adoptive Parents Parent and Step-Parent Other_____________

Other children in the family:

Name Age Sex Grade Speech/Hearing Problems

Referred by: _________________________________________________________

Cell Phone: _________________________ Telephone:_______________________
Email:_______________________________________________________________
Reason for Referral: ___________________________________________________

Other language other than English spoken at home:

No
Yes
Which one? ____________________________________________________
Do you speak the language? Yes No
Do you understand the language? Yes No
Who speaks the language?____________________________________________
Which language do you prefer to speak at home?__________________________
CASE HISTORY
Birth History

Were there any complications about the pregnancy or birth?

No
Yes
Please describe? _______________________________________________
___________________________________________________________________
___________________________________________________________________

Was the mother sick during the pregnancy?

No
Yes
Please describe? _______________________________________________
___________________________________________________________________
___________________________________________________________________

How many months was the pregnancy? __________

Did the child go home with his/her mother from the hospital?
No
Yes
Please describe? _______________________________________________
___________________________________________________________________
___________________________________________________________________

Medical History
Has your child had any of the following?
o Adenoidectomy o Encephalitis o Seizures
o Allergies o Flu o Sinusitis
o Breathing o Head injury o Sleeping difficulties
difficulties
o Chicken pox o High fevers o Thumb/finger
sucking habit
o Colds o Measles o Tonsillectomy
o Ear infections o Meningitis o Tonsillitis
o Ear tubes o Scarlet fever o Vision problems

Other serious injury/surgery:_____________________________________________

Is your child currently (or recently) under a physician’s care?___________________
___________________________________________________

Please list any medications your child takes regularly:_________________________

CASE HISTORY
Is your child currently seeing other medical professionals or therapists?
No
Yes
Please indicate below which professionals and the child’s schedule of
meetings for each
MEDICAL PROFESSIONALS SCHEDULE

Developmental history
Please tell the approximate age your child achieved the following developmental milestones
____________ Sat alone ____________ Grasped crayon/pencil
____________ Babbled ____________ Said first words
____________ Put two words together ____________ Toilet trained
____________ Walked ____________ Spoke in short
sentences
Does your child……
o Choke on food or liquids?
o Currently put toys/objects in his/her mouth?
o Brush his/her teeth and/or allow brushing

Current Speech-Language Hearing

Does your child……
o Repeat sounds, words or phrases over and over?
o Understand what you are saying?
o Retrieve/point to common objects upon request (ball, cup, shoe)?
o Follow simple directions (“shut the door” or “get your shoes”)
o Respond correctly to yes/no questions?
o Respond correctly to who/what/where/when/why questions?
CASE HISTORY
Your child currently communicates using….
o Body language
o Sounds (vowels, grunting)
o Words (shoe, doggy, up)
o 2 to 4 word sentences
o Sentences longer than four words
o Other ______________________________

Behavioural characteristics:
o Cooperative o Restless
o Attentive o Poor eye contact
o Willing to try new activities o Easily distracted/short attention
o Plays alone for reasonable length of time o Destructive/aggressive
o Separation difficulties o Withdrawn
o Easily frustrated/impulsive o Inappropriate behavior
o Stubborn o Self-abusive behavior

School History
If child is in school, please answer the following

Name of school and grade in school: _____________________________________

Teacher’s name: _____________________________________________________

Has your child repeated a grade? ____________________________

What are your child’s strengths and/or best subjects? ________________________

Is your child having difficulty with any subjects? _____________________________

Is your child receiving help in any subjects? ________________________________

Additional comments
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