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CHILD CASE HISTORY FORM
According to our records, you have requested a speech and language evaluation for
your child. In order to prepare and conduct the most meaningful evaluation for your
child, we would like you to provide the following information. Please answer all questions
as completely and accurately as possible. If you have any other information from other
professionals, such as medical records or school evaluations, please forward copies of
those documents along with this case history form. If you have any questions, please
feel free to contact us.
GENERAL INFORMATION (Print Clearly)
Child's Name:_______________________________ Date______________________
Child’s Preferred Name (if different) _________________Date of Birth______________
Age____________Child’s Social Security #___________________________________
Address:____________________________________ Telephone:________________
City:________________________________________ Zip Code: ________________
If adopted, at what age_____________School Child Attends_____________________
What is the child's primary language?_______________________________________
What is the parents’ primary language?______________________________________
Does the child live with both parents?: ______________________________________
Who is the child’s primary caregiver? _______________________________________
What is the caregiver’s primary language? ___________________________________
FAMILY INFORMATION
Mother's Name:______________________________ Age: ______________
Mother's Education:____________________Occupation_________________
Cell Phone:____________________ Business Phone___________________
Mother’s Employer_______________________________________________
Employer’s Address______________________________________________
Mother’s Social Security #_______________________________________
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Father's Name:_______________________________ Age: _____________________
Father's Education: ____________________Occupation_________________________
Cell Phone________________________ Business Phone:______________________
Father’s Employer_______________________________________________________
Employer’s Address______________________________________________________
Father’s Social Security #_________________________________________________
Brothers and Sisters (names and ages):
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name_________________________________________________
Relationship to Child________________________Phone________________________
REFERRAL INFORMATION
Referred By:___________________________________________________________
Phone:________________________ Address: _______________________________
Pediatrician:___________________________________ Telephone:______________
Address: ______________________________________________________________
SPEECH AND LANGUAGE
**Please describe your child’s speech or language difficulties in your own words.
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RECEPTIVE LANGUAGE (Check All That Apply)
My child understands:
_____single words
_____yes/no questions
_____sentences
_____wh-questions (e.g., where, when, who)
_____routine requests (e.g., sit down, stop) _____conversation
EXPRESSIVE LANGUAGE
When did your child:
Babble? ____________________
say his/her first word? ____________________
Combine 2 words? ____________
use complete sentences? _________________
My child uses the following modes of communication (check all that apply):
______ gestures
_____ phrases
______ sign language
_____ sentences
______ words (about how many _____)
_____ conversation
When did you become concerned about your child’s speech?
What do you think may have caused your child to have this difficulty?
Has your child’s speech and language become worse or has it gotten better over time?
Is your child self-conscious about his/her speech or language?
Is there any history of speech, language or hearing difficulties in your family? If so, please
describe.
Have any other speech/language professionals seen your child? If so, who and when? What
were their conclusions or suggestions?
Have any other specialists (psychologists, neurologists, physicians, therapists, special
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education teachers, audiologists, etc.) seen your child? If so, indicate type of specialist, when
the child was seen, and any conclusions or suggestions.
Is your child currently receiving any speech, language or occupational therapy? Where?
PRENATAL AND BIRTH HISTORY
During pregnancy, did the mother experience any unusual illnesses or accidents, or require
any medication, etc.?
Length of pregnancy:_________________________ Length of Labor: _____________
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?
Were there any unusual conditions immediately following birth?
Did your infant have difficulty starting to breathe?
Was your infant jaundiced?
Did your infant have an extended hospital stay? If so, please explain.
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MEDICAL HISTORY
Provide approximate ages at which your child experienced any of the following illnesses or
conditions:
Allergies _____________
Asthma _______________
Chicken Pox ___________
Colds
Croup ______________
Dizziness ___________
____________
Draining Ear ________
Ear Infections ______________________________
Encephalitis _________
German Measles ____________________________
Headaches__________
High Fever ___________
Influenza ___________
Mastoiditis __________
Measles _____________
Meningitis ___________
Mumps_____________
Pneumonia___________
Seizures ____________
Sinusitis ____________
Tinnitus _____________
Tonsillitis____________
Other:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Has your child had any surgeries? If so, what type and when.
Describe any major accidents or hospitalizations.
Does your child have a medical diagnosis? Please specify
Does your child have any allergies? If so, specify.
Is your child taking any medications? If so, please list.
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Has your child had any negative reactions to medication? Please describe.
Are your child’s immunizations up to date?
Is your child sensitive to latex?
DEVELOPMENTAL HISTORY
Provide the approximate age at which your child began the following activities:
Crawl: ____________ Sit: ____________ Stand: ____________ Walk: _____________
Feed Self: _____________ Dress Self: _______________ Use Toilet: _____________
Use single words (i.e., mommy, doggie, no, etc.) ______________________________
Combine words (i.e., me go, daddy shoe, etc.) ________________________________
Name single objects (i.e., dog, car, tree, etc.) _________________________________
Use simple sentences (i.e., Where's daddy?, etc.) _____________________________
Engage in conversation: __________________________________________________
Does your child consistently respond to sound (doorbell, name, etc.)?
Does your child seem to have difficulty hearing speech?
Has your child ever had a hearing test? Where and When? Provide results.
Does your child have any apparent vision problems?
Is it difficult for you or others to understand your child’s speech?
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Are there any specific sounds that you feel your child makes incorrectly?
Does your child seem to have difficulty understanding directions?
Does your child have difficulty attending to tasks or play activities? Please describe.
Does your child ever engage in excessive repetition of words or sentences that he/she has
heard other people say?
Does your child have difficulty walking, running or participating in activities that require
muscle coordination? Please describe.
Are there, or have there ever been, any feeding problems (difficulty sucking, chewing,
swallowing, drooling, etc.)? Please describe.
Does your child attend school? If yes, please provide school and grade level. How is he/she
doing academically?
Does your child receive special education services in the school setting? Please describe.
How does your child interact with others (i.e., aggressive, uncooperative, shy, age
appropriate, etc.)?
Are there specific things that make your child angry or afraid? Specify.
What are your child’s favorite activities at home?
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List any special interests. (i.e., dinosaurs, computer games, Barney, etc.).
Whom does your child spend most of his time with?
If your child has had an Individualized Education Plan (IEP), please provide the primary
diagnosis.
Please list the primary goals.
Please provide any additional reports or information that might be helpful in the
evaluation and/or remediation of your child's speech/language problem.
Person completing form: ___________________________________________
Relationship to child: ______________________________________________
Signature:___________________________________Date:________________