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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