Pediatric Case History Information
I.
Case History Information
Patient Name_________________________Birthdate____________________
Favorite name or nickname for your child_______________________________
Does your child have
a favorite name for you or any other relatives? ___________
_______________________________________________________________
___ Number of other children in the family and their names:_________________
Does your family have
a pet?
___ Yes ___ No
If yes what do you call them? ______________________________________________________________
Preschool/School (if school age): ______________________________________________________________
Who referred you_________________________________________________
Has your child received
any testing by outside sources for language, voice, speech, reading, hearing
or in any other related area in the last 12 months?
Yes ____ No ____
Type of testing received:
______________________________________________________________
______________________________________________________________
**You may bring copies of the above tests to your evaluation**
What are your concerns? (check all that apply)
| ___ no language | ___ lack of language | ___ unable to understand |
| ___ stutters | ___ voice quality | ___ other_____________ |
How
did you become aware of your child’s speech problems?
______________________________________________________________
______________________________________________________________
When was the problem first noticed?
__________________________________________
______________________________________________________________
Is there any other family history
of a communication problem(s)? (Describe)_____
______________________________________________________________
II. Medical History
| Yes | No | Unsure | |
| 1. Were there any problems during pregnancy or difficulties at birth? | |||
|
2. Was your child born before the due date? |
|||
| 3. Has your child been hospitalized at any time? | |||
| 4. Are there any diagnosed
mental, physical, or emotional disabilities? |
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| 5. Does your child have any allergies? | |||
| 6. Were there any sucking,
feeding, or swallowing problems? |
|||
| 7. Any drooling problems? | |||
| 8. Is there a history of ear infections? | |||
| 9. Has hearing been tested? |
a. Who was the hearing tested by:
___ physician ___ audiologist ___ school ___ other
b. Results were: ___ normal ___ abnormal (Explain): ______________________
______________________________________________________________
If you checked “yes” to any of the above please explain or describe
below.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
III. Developmental
History
Were developmental milestones (creeping on all four limbs, crawling, sitting,
standing, walking) achieved on time?
___ Yes ___ No
If no, what was unusual about achievement of the milestones?
______________________________________________________________
______________________________________________________________
Did/ does your child (check all that apply):
| ____ coo as an infant | ____ babbles as a toddler |
| ____ readily imitates sounds and words | ____ vocalizes while playing(i.e. car sounds) |
| ____ play pattycake / peek-a-boo | ____ play alternating turn or reciprocal games |
| ____ copies intonational patterns | ____ plays with cars/ dolls appropriately |
Does your child have frequent interactions
with other children? (i.e. playing with siblings, attending daycare, etc.)
___ Yes ___ No Describe: _________________________________________
IV. Understanding Language
When you talk to your child, how much does he or she understand? Check one:
| ___ a few words (i.e. body parts or identify pictures in a book) |
| ___ simple directions |
| ___ many words and phrases |
| ___ almost everything I say |
Does your child answer when you
talk to him/her?
___ Yes ___ No
Additional comments/examples can
be helpful, please use the space below.
______________________________________________________________
______________________________________________________________
Is your child attentive while books
are being read to him/her?
___ Yes ___ No (If yes, for how long? ____________)
V. Communicating with You and Your Family
How does your child usually let you know what he or she wants? (Check all that apply.)
| ___ cries | ___ uses a few words |
| ___ points to what he/she wants | ___ says many words, one word at a time |
| ___ uses gestures | ___ uses two or three word sentences |
| ___ makes a few sounds | ___ uses long sentences |
| ___ makes many different sounds | ___ asks questions |
| ___ indicates “yes” or “no” | ___ gestures or says “hi” or “bye” |
___ other ______________________________________________________
Additional comments/examples can
be helpful, please use the space below.
______________________________________________________________
______________________________________________________________
Can the family understand your
child’s speech?
___ Yes ___ No
Can people outside of the family
understand your child’s speech?
___ Yes ___ No
What does your child like to talk
about? Please explain below:
______________________________________________________________
Does your child stutter?
___ Yes ___ No
(If yes, when or how did it begin and did it go away?) ______________________________
If your child stutters, has it
gotten progressively worse?
___ Yes ___ No
If your child stutters, is there
a family history of stuttering?
___ Yes ___ No
Is there any other information
that would be helpful in preparing for your child’s evaluation?
______________________________________________________________
______________________________________________________________
______________________________________________________________