PDF SPEECH-LANGUAGE-HEARING CASE HISTORY FORM - Super Duper
SPEECH-LANGUAGE-HEARING CASE HISTORY FORM
Identifying and Family Information: Child's Name: Father's Name: Address:
Mother's Name: Address:
Doctor's Name:
Birthdate: Daytime Phone: Cell Phone: E-mail:
Daytime Phone: Cell Phone: E-mail:
Doctor's Phone:
Sex: K M K F
Child lives with (check one):
K Birth Parents K Adoptive Parents
K Foster Parents K Parent and Step-Parent
K One Parent K Other ___________
Other children in the family:
Name
Age Sex Grade
Speech/Hearing Problems
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Child's race/ethnic group:
K Caucasian, Non-Hispanic K Native American
K Hispanic K Asian or Pacific Islander
K African-American K Other ___________
Is there a language other than English spoken in the home? K Yes K No
If yes, which one?________________________________________________________
Does the child speak the language?
K Yes K No
Does the child understand the language?
K Yes K No
Who speaks the language? ________________________________________________
Which language does the child prefer to speak at home? _________________________
Sp
?2004 Super Duper? Publications ? 1-800-277-8737 ?
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Speech-Language-Hearing
Do you feel your child has a speech problem?
K Yes K No
If yes, please describe. __________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you feel your child has a hearing problem?
K Yes K No
If yes, please describe. __________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Has he/she ever had a speech evaluation/screening? K Yes K No
If yes, where and when? __________________________________________________________ What were you told? _____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Has he/she ever had a hearing evaluation/screening? K Yes K No
If yes, where and when? _________________________________________________________ What were you told? _____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Has your child ever had speech therapy?
K Yes K No
If yes, where and when? _________________________________________________________
What was he/she working on? _____________________________________________________
__________________________________________________________________________________
Has your child received any other evaluation or therapy (physical therapy, counseling, occupational
therapy, vision, etc.)?
K Yes K No
If yes, please describe.___________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Is your child aware of, or frustrated by, any speech/language difficulties?_________________________ __________________________________________________________________________________
What do you see as your child's most difficult problem in the home? ___________________________ __________________________________________________________________________________
What do you see as your child's most difficult problem in school?______________________________ __________________________________________________________________________________
?2004 Super Duper? Publications ? 1-800-277-8737 ?
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Birth History
Was there anything unusual about the pregnancy or birth?
K Yes K No
If yes, please describe. ___________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How old was the mother when the child was born? _______________
Was the mother sick during the pregnancy?
K Yes K No
If yes, please describe. __________________________________________________________
__________________________________________________________________________________
How many months was the pregnancy?___________
Did the child go home with his/her mother from the hospital? K Yes K No
If child stayed at the hospital, please describe why and how long. ________________________ __________________________________________________________________________________ __________________________________________________________________________________
Medical History
Has your child had any of the following?
K adenoidectomy K allergies K breathing difficulties K chicken pox K colds K ear infections
How often?__________
K ear tubes
K encephalitis K flu K head injury K high fevers K measles K meningitis K mumps K scarlet fever
K seizures K sinusitis K sleeping difficulties K thumb/finger sucking habit K tonsillectomy K tonsillitis K vision problems
Other serious injury/surgery: ________________________________________________________
Is your child currently (or recently) under a physician's care? K Yes K No
If yes, why?___________________________________________________________________ __________________________________________________________________________________
Please list any medications your child takes regularly: _______________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
__________________________ ?2004 Super Duper? Publications ? 1-800-277-8737 ?
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Developmental History
Please tell the approximate age your child achieved the following developmental milestones:
__________ sat alone __________ babbled __________ put two words together __________ walked
__________ grasped crayon/pencil __________ said first words __________ spoke in short sentences __________ toilet trained
Does your child...
K choke on food or liquids?
K currently put toys/objects in his/her mouth?
K brush his/her teeth and/or allow brushing?
Current Speech-Language-Hearing
Does your child...
K repeat sounds, words or phrases over and over? K understand what you are saying? K retrieve/point to common objects upon request (ball, cup, shoe)? K follow simple directions ("Shut the door" or "Get your shoes")? K respond correctly to yes/no questions? K respond correctly to who/what/where/when/why questions?
Your child currently communicates using...
K body language. K sounds (vowels, grunting). K words (shoe, doggy, up). K 2 to 4 word sentences. K sentences longer than four words. K other _____________________________.
Behavioral Characteristics:
K cooperative K attentive K willing to try new activities K plays alone for reasonable length of time K separation difficulties K easily frustrated/impulsive K stubborn
K restless K poor eye contact K easily distracted/short attention K destructive/aggressive K withdrawn K inappropriate behavior K self-abusive behavior
?2004 Super Duper? Publications ? 1-800-277-8737 ?
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School History
If your 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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