Case History Form
Instructions: To assist me in providing a comprehensive
evaluation of your child, please answer ALL THE QUESTIONS
as completely as possible.
Child’s Name: _____________________________ Date of Birth: ________________ Age: ______
Address: __________________________________________________________________________
Home Phone: _________________ Cell Phone: ___________________ Email: ___________________
Mother’s Name: __________________________ Father’s Name: _____________________________
Siblings, Ages: ______________________________________________________________________
If BCBS IL insurance, what is the primary cardholder’s name? __________________________________
Date of Birth:________________ Policy #: ____________________________ Group #: ___________
How would you describe your child’s problem? What questions do you have? ______________________
__________________________________________________________________________
__________________________________________________________________________
Has your child seen any other specialist regarding these concerns? ____________________________
__________________________________________________________________________
Is there anyone else in your immediate or extended family who have or have had similar problems? Describe.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Pregnancy/Birth History:
Weeks at birth: _____
Weight: _____lbs. _____ozs.
Complications (during pregnancy or post-partum): ___________________________________
____________________________________________________________________
Current growth percentile for:
Height _____ Weight _____
Medical History:
Current Medications & why: ______________________________________________________
___________________________________________________________________________
Previous Hospitalizations/Prolonged Medical Treatment: _________________________________
___________________________________________________________________________
Surgeries: ___________________________________________________________________
History of Ear Infections? ____________________ How many since birth? _________________
Developmental History: Age at which the child did the following:
Crawled: ___________________
Walked independently: ________
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Feeding History: Does your child have any difficulty with the following?
_____ Drooling
_____ Picky eater
_____ Frequent Vomiting
_____ Moving Tongue
_____ Food Allergies
_____ Sleeping
_____ Weight loss/lack of weight gain
_____ Feeding Self
_____ Sucking
_____ Gagging/Choking
_____ Snores
_____ Chewing
_____ Swallowing
_____ Breathing
_____ Other
Speech & Language Development:
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5.
6.
7.
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12.
My child was a _____ Quiet baby
_____ Average noisy baby
_____ Very noisy baby
My child enjoyed mouthing objects: _____ minimal
_____ average
_____ very much
My child has exhibited “oral groping” behaviors where he/she struggles to get a sound/word out.
___ Yes
___ No
When did your child’s first words emerge?: ________months
What were they?______________________________________________________________
My child used to say a few words, but then stopped saying them.
___ Yes
___ No
How many words can your child say now? _____________________________________________
2-3 word utterances emerged: _____________ months
Used complete sentences at: _____________ months
Is your child aware of his difficulty communicating with you? _____________________________
Does your child get frustrated when he/she speaks? ____________________________________
___________________________________________________________________________
How does your child typically communicate with you? ____________________________________
___________________________________________________________________________
What percentage of your child’s speech (25%, 50%, 75% 90%) is understood by:
A familiar listener? _________%
An unfamiliar listener? _________%
Social/Emotional: Please describe:
1.
2.
3.
4.
Discipline (type, response, etc.) ____________________________________________________
Fears? ______________________________________________________________________
Length of time child plays at one activity ____________________________________________
Nervous Habits/Irregular behaviors? _______________________________________________
___________________________________________________________________________
Educational Development:
Has your child ever attended preschool, daycare, play group, nursery school or any extracurricular
program? YES ______
NO ______
My child currently attends:
____________________________________________________
How often?
_____ days/week
______ hours/day
Specialists Involved In Your Child’s Care:
NAME
PHONE NUMBER
Pediatrician: ___________________________________________________________
ENT: ________________________________________________________________
Neurologist: ___________________________________________________________
Cardiologist: ___________________________________________________________
Psychologist: __________________________________________________________
Speech Language Pathologist: ______________________________________________
Occupational Therapist: __________________________________________________
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Physical Therapist: ______________________________________________________
Audiologist: ___________________________________________________________
Other: _______________________________________________________________
How did you hear about the Smiling Star Center for Speech and Language?
(please include name and address)
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Early Childhood program (name): _____________________________________________
My child’s school (name): ___________________________________________________
My child’s pediatrician (name): _______________________________________________
Local park district: _______________________________________________________
Yellow Book: ____________________________________________________________
Yellow Book Online: _______________________________________________________
Friend Referral: _________________________________________________________
Other: ________________________________________________________________
Please mail this back prior to one week of your appointment.
My review of this information prior to your visit will allow me to complete the most comprehensive
assessment on your child and maximize your and your child’s time during your visit.
I look forward to meeting you!
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