APPENDIX 1-A
Child Case History Form
I.
General Information
Child’s Name:___________________________________ Birthdate:______________
Legal Guardian’s Name: ____________________________________________________
Relationship to Child: ______________________________________________________
Primary Language in the home: ___________________________________
Child’s Primary Language: ___________________________________
Other Language(s) spoken by the child: ___________________________________
Child’s Brothers and Sisters (include names and ages):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
With whom does the child spend most of his or her time (Home, Daycare, School, Other)?
II.
Background Information
Who referred you to our center? ___________________________________
Describe the child’s speech-language problem.
When was it first noticed and by whom?
How does the child usually communicate (gestures, single words, phrases, sentences)?
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
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Have there been any changes to your child’s speech/language or hearing since that time? ____Yes ____No
If yes, please explain:
Is the child aware of the problem? ____Yes ____No
If yes, how does he or she feel about it?
Has a Medical Professional been consulted regarding the problem? ____Yes ____No
If yes, by whom:
What were the results of this evaluation?
Has your child ever had an evaluation from an Ear, Nose and Throat Medical doctor? ____Yes ____No
If yes, by whom?
What were the results of this evaluation?
Has your child’s hearing been tested? ____Yes ____No
If so, where was the testing and when was it done?
Describe the child’s response to all sound (e.g., responds to loud sounds only, inconsistently responds to sounds,
etc).
Have any other speech-language specialists seen the child? ____Yes ____No
If yes, by whom?
What were their conclusions or suggestions?
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
Is there any other speech, language, or hearing problems in your family? ____Yes ____No
If yes, please describe:
Have any of the following conditions affected members of your immediate family? (Check all that apply)
□Deafness
□Neurologic
□Diseases
□Stuttering
□Delayed Speech
□Cleft Lip & Palate
□Delayed Motor Skills
□Other:
Have any other specialists (physicians, psychologists, special education teachers, occupational therapists, physical
therapists, etc.) seen the child? ____Yes ____No
If yes, indicate the type of specialists, when the child was seen, and the specialist’s conclusions or suggestions
(include IEP with school)
Prenatal and Birth History
Did the mother have any of the following during pregnancy? (Please check all that apply)
□Bleeding
□Virus Infection
□Toxemia
□Swelling
□German Measles-Rubella
□Medications
□High Blood pressure
□Diabetes
□Anesthesia
□Low blood pressure
□Heart Condition
□Kidney Disease
□Convulsions
□Asthma
□Accidents
□Excessive weight gain/loss
□Thyroid Condition
□Drinking alcohol
□Smoking
□Surgeries
□Other:_______________
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
Mother’s general health during pregnancy (illness, accidents, medications, etc.)
Length of pregnancy:___________________________ Length of Labor:____________________________
General condition:_____________________________ Birth weight:_______________________________
Circle type of delivery:
head first
Feet first
Breech
Caesarian
Were there any unusual conditions that may have affected the pregnancy or birth?
Medical History
Did or Does your child have problems with any of the following?
□Feeding/swallowing
□Convulsions
□Severe Jaundice
□Heart or Breathing
□Serious Infections
□Severe Reflux
□Other________________________________________
Has your child experienced any of the following? Please include age and severity.
□Mumps
□Chicken Pox
□Influenza
□Measles
□Pneumonia
□Headaches
□Sinus
□Meningitis
□Dental Problems
□Tonsillectomy
□Adenoidectomy
□Allergies
□Epilepsy
□Asthma
□Encephalitis
□Tonsillitis
□Chronic Colds
□Head Injuries
□Ear Infections
□Draining Ears
□P.E. Tubes Insertion
□Other Illnesses, Surgeries, Hospitalizations:
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
Is your child presently taking any medication? ____Yes ____No
If yes, please list any medications:________________________________________________________
Developmental History
Provide the approximate age at which the child began to do the following activities:
Crawl________________________ Sit________________________ Stand_________________________
Walk________________________ Feed self___________________ Dress self______________________
Use toilet____________________
At what age did your child vocalize?_________________________________________________
At what age did your child use single words (e.g., mama, dada, dog)?_____________________________
What age did your child begin to use two words together (e.g., more juice; go bye-bye)?______________
What age did your child begin to use sentences?____________________________________________
What age did your child use simple questions (e.g., where’s the doggie?)?
Engage in a conversation?_________________________________________________________________
How well can your child be understood by his/her parents?
How well can he/she be understood by other family members?
How well can he/she be understood by new people?
How many words are in your child’s vocabulary?
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
Which of the follow does your child use to communicate?
□sentences
□sounds
□phrases
□cries
□one-two words
□gestures
□Communication Board (e.g., PECS)
Do you question your child’s ability to understand directions/conversation? ____Yes ____No
If yes, explain:
Do you question your child’s ability to express him or herself? ____Yes ____No
If yes, explain:
Does the child have any difficulty walking, running, or participating in other activities which require small or large
muscle coordination?
Are there, or have there ever been, any feeding problems (e.g. problems with sucking, swallowing, drooling,
chewing, etc.)? ____Yes ____No
If yes, describe.
Does your child demonstrate the following? (Please check all that apply)
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Licks or smells non food items
Avoids certain foods
Enjoys playground play (swings/slides)
Avoids having feet off ground
Takes risks during play
Prefers activities that are less active
Walks on toes
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Avoids being barefoot on some surfaces
Seeks out hugs/touch
Rough play
Resists being touched/hugged
Avoids or is upset by being messy
Gets upset by certain noises
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
How does your child prefer to play, alone or with other children?
Does your child have temper tantrums? ____Yes ____No
Does your child get along with other children? ____Yes ____No
Does your child demonstrate aggressive or uncooperative behaviors toward other children?
____Yes ____No
Is your child usually quiet? ____Yes ____No
Is your child usually active? ____Yes ____No
Does your child spin around self, toys, flaps hands or fingers? ____ Yes____No
Does your child repeat words? ____ Yes____No
Does your child not initiate conversation? ____ Yes____No
Does your child avoid eye contact or look away? ____ Yes____No
Is your child resistant to physical contact (hugs or kisses)? ____ Yes____No
Is your child insistent on routine? ____ Yes____No
Does your child line up toys, inappropriate play with objects or demonstrate unusual play with objects? ____
Yes____No
Did your child demonstrate loss of language at a specific age and if so what level were they communicating at (i.e.
word, phrase)? ____ Yes____No
Does your child demonstrate reciprocal conversation? ____ Yes____No
Does your child demonstrate inappropriate or repeated use of questions? ____ Yes____No
Does your child display verbal rituals (i.e. tv or movie talk)? ____ Yes____No
Does your child have unusual intonation or volume rate? ____ Yes____No
Does your child point to express interest? ____ Yes____No
Is your child a picky eater or exhibit sensitivity to specific foods? ____ Yes____No
Does your child seek to share enjoyment with others? ____ Yes____No
Does your child play or interested in peers? ____ Yes____No
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com
Is your child aggressive towards family, other children, or injury to self? ____ Yes____No
Does your child have unusual strength in visuospatial abilities? ____ Yes____No
Is your child sensitive to loud noises, touch, smell, or taste? ____ Yes____No
Does your child exhibit difficulty following directions? ____ Yes____No
Does your child have difficulties attending or following your directions? ____Yes ____No
Does your child have difficulties tolerating transitions or unexpected changes in his/her routine?
____Yes ____No
Is there anything about your child’s behavior that concerns you? ____Yes ____No
Please explain:
Educational History
School:___________________________________________________________Grade:_______________
Teacher(s):_____________________________________________________________________________
How is the child doing academically (or pre-academically)?
Does the child receive special services? If yes, describe.
4300 Rose Drive  Yorba Linda, CA 92886
T: (714) 528-4211
www.sjhmg.com