Express Yourself Speech Pathology Services, LLC



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Child Case History

Please answer all questions as completely as possible. The information you provide is very helpful in planning your child’s plan of care. Please note “N/A” where necessary.

Name of child: _____________________________________Date: ______________________________

Name by which your child is called: ______________________________________________________

Date of birth: _______________ Age: ____________ Gender: _________________________________

Parent(s) name(s): _____________________________________________________________________

Address(es):_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Telephone # (Home): ________________ (Work): ________________ (Cell): ____________________

Email Address(es): _____________________________________________________________________

Referred by: _____________________________ Telephone #: _________________________________

Name of person completing this form: _____________________ Relationship: __________________

Person to contact in case of emergency: ____________________ Telephone #: __________________

COMMUNICATION HISTORY

1. Please describe your child’s communication difficulty. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. When did you first notice your child’s communication difficulty? ______________________________________________________________________________________________________________________________________________________________

3. What do you think caused your child’s communication difficulty? ______________________________________________________________________________________________________________________________________________________________

4. Does your child’s communication difficulty ever become better or worse?

_____ Yes _____ No If “yes”, in what situations? ____________________________________________________________________________________________________________________________________________________________________________

5. Did your child’s speech and language development ever seem to stop for a period of time?

______ Yes ____ No If “yes”, please explain. ____________________________________________________________________________________________________________________________________________________________________________

6. Describe any problems that appear to be related to your child’s communication difficulty?

____________________________________________________________________________________________________________________________________________________________________________

7. Indicate the age at which your child. Please write “NA” if not applicable:

Began to babble __________ Had a vocabulary of 50 words ________

Said first words __________ Began to say two-word sentences________

What were they? ___________ Began to say three-word sentences ______

Began asking questions _________

Sat up ___________

Crawled ____________

Walked ___________

8. How long are your child’s typical sentences (number of words)? ________

Examples: ____________________________________________________________________________________________________________________________________________________________________________

9. How often do you understand what your child says to you?

____ Always ___ Most of the time ____Frequently

____Occasionally ___Rarely ____Never

10. How often do relatives and friends of the family understand what your child says?

____ Always ___ Most of the time ____Frequently

____Occasionally ___Rarely ____Never

MEDICAL/DEVELOPMENTAL HISTORY

1. Were there any complications before or during the birth of your child?

____ Yes ____ No

If “yes”, please describe. ____________________________________________________________________________________________________________________________________________________________________________

2. Were any medications taken during pregnancy or delivery?

___ Yes ___ No

If “yes”, please explain. ____________________________________________________________________________________________________________________________________________________________________________

3. Has your child ever been hospitalized? _____ Yes ____ No

If “yes”, please complete the information below.

Reason for Hospitalization Date (s) Length of Stay

a. __________________________________________________________________

b. __________________________________________________________________

c. __________________________________________________________________

4. Describe your child’s current health.

______ Excellent _______ Good _______ Fair ________ Poor

If “fair” or “poor”, please explain. ____________________________________________________________________________________________________________________________________________________________________________

5. Please list your child’s physicians’ names, addresses, and phone numbers.

Name Address Phone Number

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Does your child have a history of ear infections? _____ Yes ____ No

If “yes”, how many per year/when? _______________________________________

If “yes”, how were they treated? __________________________________________

7. Were tubes ever recommended or inserted? ______ Yes ____ No

8. Does your child have any other medical issues we should know of?

___ Yes ___ No If “yes”, please explain. ______________________________________________________________________________________

______________________________________________________________________________________

9. Has your child ever received physical/occupational therapy or previous/present speech therapy? ____ Yes ____ No If “yes”, please list below:

Type of Service Dates of Service Name of Therapist and Address

a.__________________________________________________________________________________________________________________________________________________________________________

b.__________________________________________________________________________________________________________________________________________________________________________

c.___________________________________________________________________________________________________________________________________________________________________________

10. What was the result of the therapy? ____________________________________________________________________________________________________________________________________________________________________________

11. Is your child currently taking any medications? ____ Yes ____ No

If “yes”, please list name of medication and reason for prescription.

____________________________________________________________________________________________________________________________________________________________________________

FAMILY HISTORY

1. Parent Name: ____________________________ Age: ___________

Occupation: _______________________ Employer: ___________________

Parent Name: _______________________ Age: ___________

Occupation: _______________________ Employer: ___________________

2. Name (s) and age (s) of other children in the family:

Name Age

____________________________________________________________________________________________________________________________________________________________________________

3. How does your child interact with his/her brothers and sisters? ____________________________________________________________________________________________________________________________________________________________________________

4. Does anyone in your family have a speech, language or hearing impairment? _____Yes ____No

If “yes”, please explain. ____________________________________________________________________________________________________________________________________________________________________________

5. Was anyone in the family a “late talker”? ____ Yes ____ No If “yes”, please explain. ____________________________________________________________________________________________________________________________________________________________________________

6. How do you discipline your child? ____________________________________________________________________________________________________________________________________________________________________________

7. Are these methods effective? ______ Yes ____ No

Please explain. ________________________________________________________________________________________________________________________________________________

8. What activities do you participate in with your child? ________________________________________________________________________________________________________________________________________________

EDUCATIONAL/SOCIAL HISTORY

1. Please provide the name of your child’s school and type of program he is currently enrolled along with the name of his classroom teacher.

Name of school Type of program Name of teacher

____________________________________________________________________________________________________________________________________________________________________________

2. Is your child currently receiving speech/language therapy? _____ Yes _____ No

If so, please list the name and contact information of his therapist and brief summary of the goals in his therapy program. ____________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

3. How does your child interact with other children/siblings? ____________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

4. What are your child’s favorite activities, toys, and interests? ____________________________________________________________________________________________________________________________________________________________________________

5. What things does your child do particularly well? ____________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL COMMENTS

Please provide any additional information which might be helpful to us in understanding your child’s speech, language, social and overall communication skills. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please return this form to:

Traci Flome

Fax to 770 696 1323 or email to traciflome@

THANK YOU!

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