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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