Pediatric Case History Form

Please complete then click the “submit” button prior to initial meeting with clinician. This information will assist in preparing for your child’s evaluation and subsequent services, as necessary.

Parent/Gaurdian name
  Child resides with Mother Father Both
Other
  Place of employment
   
    Identifying information, Re: Child
 
  Name
  Address
  City/State/Zip
  Phone
  Birthdate    Age
  School/Grade
  Siblings
        Physician info:
  Name
  Address
  City/State/Zip
  Phone
     
    Family & Client Information
 
  Is there any history of speech or language difficulties in the family?
  Describe the speech/language problem as best you can.
  Has your child ever received treatment for this problem? If so, by whom, when, how long?
  Is your child receiving any special services/tutoring? If so, by whom, when, how long?
  Are there any other development or psychosocial concerns? If so, please explain.
     
    Birth & Developmental History
     
  Was the pregnancy uneventful?
  Was there anything unusual about the delivery?
 
Was your child bottle-fed? Yes No
Was your child breast-fed? Yes No
  Please note age for the following:
First tooth Sat up
Full baby set Crawled
First tooth lost Walked
Bowel trained Fed self
Bladder trained    
  Did child easily take to:
Spoon feeding? Yes No
Cup drinking? Yes No
Use of a straw? Yes No
  Describe eating behaviors:
Rate of eating Slow Avg Fast
Amount of liquid Slow Avg Fast
Chewing with mouth open Yes No
Tongue protrusion Yes No
Noisy eater Yes No
Chews thoroughly Yes No
Other
     
    Medical History
     
  Did your child have any unusual childhood diseases? If so, please explain.
  Has your child ever had any of the following medical conditions? If so, please explain: High fevers, convulsions, alergies, frequent colds, frequent ear infections, serious injuries, unconsciousness, disorders of the Central Nervous System, cleft lip or palate, other?
 
Tonsils Present Removed
Adenoids Present Removed
  Does/did your child exhibit any of the following:
Thumb sucking If so, when?
Mouth breathing If so, when?
Bed wetting If so, when?
  Snoring Rarely Frequently Light Heavy
     
    Present Health
     
  Present medication(s):
  Is your child in good health?
 
   
Date tested
Is vision normal? Yes No
Is hearing normal? Yes No
Is child energetic? Very Fairly Not
     
    Social Behavior
     
 
Does your child get along well with other children?    Yes No
 
Does your child play with children that are:    Same age
   Older
   Younger
  What types of interests, hobbies, or amusements does your child enjoy?
  How is your child doing in school?
  Does your child like school?    Yes No
  Describe his/her disposition: (check all appropriate)
Happy Moody Friendly
Sad Quiet Affectionate
Changeable
     
    Speech/Language Behaviors
     
  Age of first:
Words Phrases Sentences
 
At what speed did your child develop vocabulary? Slow
Average
Fast
 
Did your child understand before he/she could talk? Yes No
 
Is your child... Talkative Average Silent
 
Was speech or language development generally delayed? Yes
No
 
Over the past three years, has your child’s speech become... Better
Worse
No change