Speech-Language Pathology Service



Speech-Language Pathology Service

Pediatric Speech-Language-Voice-Feeding and Swallowing Case History Form

Name:______________________________________DOB:___________________________________

Parent/Guardian’s Name: _______________________________________________________________

Child resides with: (circle one) both parents mother father other: ___________________________

Primary Phone: ______________________________ Alternate Phone: __________________________

Primary language spoken in the home: ____________________________________________________

School/Day Care: ___________________________ School District: ____________________________

Grade: ____________________________________

Why has your child been referred for this evaluation?

Medical History:

_________________________________________________________

Current Medications:__________________________________________________________________

Allergies: __________________________________________________________________________

Family Members Relationship Ages

____________________________________________________________________________________

____________________________________________________________________________________

SPEECH-LANGUAGE AND/OR COGNITION\LEARNING

SECTION 1: *DOES YOUR CHILD CURRENTLY HAVE ANY COMMUNICATION OR COGNITION/LEARNING DIFFICULTIES?

YES NO (CIRCLE ONE) *If NO, continue to next section.

Is there a history of speech, language or cognitive difficulties in the family? __YES NO_________

Describe your concerns about your child’s speech, language or cognition: ________________________

____________________________________________________________________________________

____________________________________________________________________________________

When did these problems begin and how have they changed over time? __________________________

____________________________________________________________________________________

How do these difficulties affect your child’s communication and interactions with others?____________ ____________________________________________________________________________________

____________________________________________________________________________________

Developmental History

Check those milestones that were delayed. List the age at which you first noticed the milestone.

[] sit up _________ [] crawl________ [] walk________ [] toilet________ [] dress self________

[] first word/single words________ [] combine 2-3 words________

[] use simple sentences/questions________ [] engage in conversation________

Check the following that apply to your child:

[] difficulty using words to communicate [] unable to point to/identify objects

[] uses gestures (pointing, etc…) to communicate [] difficulty understanding directions

[] difficulty being understood by others/peers [] gets frustrated when unable to communicate

[] difficulty in school with academics [] difficulty with reading or writing

VOICE

SECTION 2. *HAS YOUR CHILD HAD A CHANGE IN THE QUALITY OF HIS OR HER VOICE?

YES NO (CIRCLE ONE) *If NO, continue to next section.

Is there a history of voice difficulties in the family? __YES NO___________________________

Describe your concerns about your child’s voice: ___________________________________________________________________________________

____________________________________________________________________________________

When did these problems begin and how have they changed over time? __________________________

____________________________________________________________________________________

Check the following that describe your child’s voice.

___ hoarse ___ harsh/raspy ___ loud ___ high pitched ___ monotone

___ breathy ___ nasal ___ soft ___ low pitched

Check the following that apply to your child:

__ run out of breath while speaking __ frequently lose voice by end of day

__ daily activities include public speaking __ participate in activities/hobbies with frequent

or talking on the telephone talking, yelling, or cheering

__ others have difficulty understanding your child __ frequent cough or throat clear during the day

__ reflux or GERD __ experience neck/throat pain

__ consume alcohol or tobacco __ use products with caffeine (soda, tea, chocolate)

__ exposure to smoke, dust, chemicals, animal hair

SWALLOWING

SECTION 3. *IS YOUR CHILD HAVING ANY DIFFICULTY SWALLOWING FOOD OR LIQUID?

YES NO (CIRCLE ONE) *If NO, continue to next section.

Is there a history of swallowing difficulties in the family? ____YES NO___________________

What is your child’s current diet? ________________________________________________________

Describe your concerns about your child’s swallowing/feeding problem: ____________________________________________________________________________________ ____________________________________________________________________________________

____________________________________________________________________________________

Any associated difficulties (chewing, swallowing, drooling)? __________________________________

Circle any of the following that describe your child: picky eater / happy eater / frequent gagging / frequent vomiting / spitting up/ spitting out food

What position/where do you feed your child? (ie. high chair, lap) ______________________________

Please list any special utensils you use to feed your child: special nipple/ coated spoon/ etc…. ___________________________________________________________________________________

Which types of foods are easiest /hardest for your child? (please specify): ________________________ ____________________________________________________________________________________

How long does it take to feed your child? __________________________________________________

When did these problems begin and how have they changed over time? __________________________

Food Allergies: ___YES___NO____ If YES, please specify: _____________________________

Dietary Restrictions that include: ____WHEAT_________EGGS_________DAIRY________________

____________________________________________________________________________________

SECTION 4: *TO BE COMPLETED:

What are your primary goals for improving your child’s communication, voice and/or swallowing? ____________________________________________________________________________________

____________________________________________________________________________________

Have you ever seen a Speech Language Pathologist? NO YES: Who? ________________________

When? _______________________

What services did you receive? _______________________________________________________ What questions are you hoping to have answered from this evaluation? Is there anything we can do to help you? _________________________________________________________________________

_________________________________________________________________________________

How did you first learn about the speech language pathology program at Nuvance? ____________________________________________________________________________________

Parent/Guardian’s signature ____________________________ Date__________________________

Clinician’s signature ________________________________ Date ____________________________

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