Speech Case History Children

SPEECH CASE HISTORY – CHILDREN

Child’s Name: ______Date of Birth: ______

Address: ______Phone Number: ______

______E-mail:______

Form Completed By: ______Relationship to Child:______

Parent’s Names: ______

Please list all family members or other persons who live in the home and/or contribute to the child’s care (use reverse if necessary).

Name:______Relationship to Child:______

Referred By: ______

Address: ______Phone Number: ______

Describe the concerns regarding this child’s speech, language, hearing, development or learning: ______

______

How long have you been concerned? ______

Has this child been diagnosed with any of the following:

 ADHD Articulation/phonology

 Autism Spectrum disorder (PDD, autism, Asperger) Behavior problems

 Genetic disorders Hearing disorder

 Expressive and or receptive language disorderLearning disorder

 Oral motorfeeding Sensory integration difficulties

 Fluency disorder (stuttering, cluttering)

 Other:______

When was this diagnosis made and by whom? ______

Please describe the nature of the diagnosis: ______

Has anyone else in the family been diagnosed with any of the following problems:

 ADHD Articulation/phonology

 Autism Spectrum disorder (PDD, autism, Asperger) Behavior problems

 Genetic disorders Hearing disorder

 Expressive and or receptive language disorderLearning disorder

 Oral motor feeding Sensory integration difficulties

 Fluency disorder (stuttering, cluttering)

 Other:______

Who was diagnosed with this problem (relationship to child)______

BIRTH AND MEDICAL HISTORY:

Describe the mother’s health during this pregnancy:  Excellent  Good  Fair  Poor

Were any of the following true during the pregnancy:

 AccidentsIllnessesViruses Rashes

 Medications X-rays Treatments  Alcohol or drug use

 Injuries Other

If yes, please describe: ______

What was the length of the pregnancy? ______

Describe the baby’s condition at birth:  Excellent  Good  Fair  Poor

Was the birth: Vaginal Breech Caesarean  Instruments used

Birth Weight: ______Apgar scores (if known): ______

Conditions present during newborn period:

 Breathing difficulties Seizures Cyanosis (blue)

 Swallowing/feeding difficulties Paralysis Physical abnormalities

 Cleft lip/palate Jaundice Meningitis

 Intensive care nursery Infection Required Oxygen

 Medications administered: ______

Please describe other concerns, conditions, or treatments at birth: ______

______

Please indicate if the child has had any of the following:

 Allergies Frequent/chronic colds Measles Mumps

 Chicken Pox Thyroid condition Meningitis Seizures

 Head Injury Ear infections – How often? ______

 Other: ______

Describe any other illnesses, conditions, injuries: ______

______

Are the child’s immunizations current? ______

Please list any medications the child is taking: ______

Describe any hospitalizations the child has had: ______

______

Child’s Racial/Ethnic Background:
☐African-American / ☐Asian Pacific / ☐Caucasian / ☐Hispanic or Latino
☐Native American / ☐More than one race / ☐Other: ______

SPEECH, LANGUAGE & DEVELOPMENTAL HISTORY

At what age did the child:

Sit alone? _____Crawl?_____Walk Alone? _____

Babble? _____Use first words? _____Use simple sentences? _____

Does your child eat a variety of foods?  Yes  No Comments: ______

Does your child feed him/herself?  Yes  No Comments: ______

Does your child drink from a cup?  Yes  No Comments: ______

Does your child eat with a spoon/fork?  Yes  No Comments: ______

Did the child ever start talking and then stop for any period of time?  Yes  No

Please explain: ______

Does the child prefer to gesture rather than use speech to communicate?  Yes  No

What languages are spoken in the home? ______

What languages are spoken by the child:______

Does your child talk:  Frequently Occasionally  Rarely Never

Is the child learning new words on a weekly basis?  Yes  No

Give some examples of words and sentences that your child might say:______

Is the child’s speech difficult to understand? Yes  No

How much of the child’s speech is understood by:

Family members? _____%Unfamiliar listeners? _____%

Which speech sounds seem to be difficult for the child to say? ______

Do you believe your child’s communication difficulties are affecting progress in school? Yes  No

(Explain:______)

Please describe any current or previous speech-language or developmental evaluations or therapy:

______

While keeping your child’s current age in mind, please rate the following:

Motor coordination and balance
(e.g. walking, skipping, hopping, running) /  Excellent /  Good /  Fair /  Poor /  Unknown
Hand/eye coordination
(e.g. stacking blocks, coloring, writing, feeding) /  Excellent /  Good /  Fair /  Poor /  Unknown
Which hand does the child prefer to use? /  Right /  Left /  Either
Vision /  Excellent /  Good /  Fair /  Poor /  Unknown
Does the child use glasses? /  Yes /  No
General behavior at home /  Excellent /  Good /  Fair /  Poor /  Unknown
General behavior at school/pre-school /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to play with other children /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to play appropriately with toys/games /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to remember familiar people/places /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to solve problems/puzzles /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to respond appropriately to discipline /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to control frustration /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to keep attention on an activity /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to maintain an appropriate activity level /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to not become distracted /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to think before acting
(e.g. doesn’t behave impulsively) /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to sit still
(e.g. is not “fidgety” or restless) /  Excellent /  Good /  Fair /  Poor /  Unknown
Describe the child’s self-esteem /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to follow single instructions /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to follow multiple instructions /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to find the right words when talking /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to use correct grammar when talking /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to understand questions /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to understand space/time/quantity concepts /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to recall spoken information /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to recite familiar nursery rhymes /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to tell or re-tell a story /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to talk about events in proper order /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to have a conversation with adults /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to have a conversation with children /  Excellent /  Good /  Fair /  Poor /  Unknown
Takes appropriate turns in conversations /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to maintain the topic of conversation /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to get the point across while talking /  Excellent /  Good /  Fair /  Poor /  Unknown
Ability to maintain eye contact while talking /  Excellent /  Good /  Fair /  Poor /  Unknown

Please explain any areas above receiving ratings of fair or poor: ______

Describe any unusual, slow development or behaviors that have concerned you:______

AUDITORY BEHAVIOR

Does the child respond to various sounds in the environment? /  Yes /  Sometimes /  No
Does the child startle to loud sounds? /  Yes /  Sometimes /  No
Can the child correctly locate the source of sounds? /  Yes /  Sometimes /  No
Does the child respond to face-to-face speech? /  Yes /  Sometimes /  No
Does the child respond to speech from a distance? /  Yes /  Sometimes /  No
Does the child respond to speech in noisy environments? /  Yes /  Sometimes /  No
Does the child frequently ask for repetition? /  Yes /  Sometimes /  No
Does the child appear to be a good listener? /  Yes /  Sometimes /  No

Has the child ever been found to have a hearing loss?  Yes No

Explain previous hearing tests and results: ______

Does the child wear hearing aids?  Yes No

If yes, please explain:______

Has the child ever been seen by an ear specialist physician (ENT/Otolaryngologist)?  Yes No

For what reason? ______

Do any blood relatives (siblings, parents, grandparents, cousins, aunts/uncles) have hearing loss?

If yes, please describe______ Yes No

Please describe any concerns regarding the child’s listening/hearing abilities: ______

SCHOOL PERFORMANCE

Name of school/pre-school:______Phone:______

Address:______City: ______ZIP: ______

Grade enrolled: ______Placement: Regular Resource Special education

Please describe any academic support services, tutoring, special classes, or therapy that your child receives in school: ______

Has an IFSP, IEP, or 504 Plan been completed? (If yes, when? ______)  Yes  No

Primary teacher:______Resource/Special Ed. Teacher:______

School performance is:  Excellent  Good  Fair  Poor

Has the child ever failed or repeated a grade?  Yes  No

If yes, please explain:______

Has the child had any academic or other problems in school? /  Yes /  No
If yes, please explain:______
In what school subjects does the child have particular difficulty?______
In what school subjects does the child do well?______
Does the child have difficulty sounding out words when reading? /  Yes /  No
Does the child have difficulty understanding what he/she reads? /  Yes /  No
Does the child have difficulty recalling what he/she has read? /  Yes /  No
Does the child have difficulty spelling after adequate practice? /  Yes /  No
Does the child have difficulty writing complete sentences or paragraphs? /  Yes /  No
Does the child become distracted easily in the classroom? /  Yes /  No
Does the child have difficulty paying attention during teacher instruction? /  Yes /  No
Does the child readily follow the teacher’s directions? /  Yes /  No
Does the child have difficulty completing in-class assignments? /  Yes /  No
Does the child know and understand homework assignments? /  Yes /  No

______

Please provide any other information or describe any other concerns you may have at this time.

______

Please list the names and contact information for physicians, clinics, schools, teachers, therapists, or other professionals who are involved with or are providing services to this child. Check the box if you would like that person to receive a report of this evaluation

NAME/AGENCY / ADDRESS (include city & zip code) / PHONE / REPORT?

Please provide the ASU Speech and Hearing Clinic with any previous reports from other agencies about your child’s pertinent medical, educational, psychological, hearing and speech-language status. If you do not have copies of these reports, please add those agencies to the above table, and sign below to indicate we have permission to contact them to gather necessary information.

I give my permission for the ASU Speech and Hearing Clinic to contact teachers, physicians, and professionals/agencies listed above to obtain information about my child’s communication and learning abilities.

Signature of Parent/Guardian:______Date: ______