Camp CHRONICLE 2017

DEVELOPMENT HISTORY FORM

The information provided on this form will assist in planning and providing the appropriate services for the child. All information will be a part of the child’s record and will be confidential. Information may be stated in the report unless requested that it be kept private. Thank you for your help.

Child’s Name:

Date of Birth: Age: Sex:

Parent/ Guardian Name:

Work Phone:

Home Phone:

Cell Phone:

Email:

Additional Parent/Guardian Name:

Child’s Address

School:

Grade (current or just completed):

Teacher:

Child’s Doctor:

Doctor’s address or name of clinic:

Phone number:

Family members in the household

Name / Age

Name of person completing this form:

Relationship to child :

______

STATEMENT OF THE PROBLEM

Please briefly describe your child’s reading/writing abilities (why are you interested in enrolling him/her in Camp CHRONICLE?)
Has your child ever been diagnosed with a learning disability? If so, please describe (e.g., dyslexia, reading disability, ADD)
Is this the first language/literacy evaluation? If not, who else has seen the child, when, and what were you told?

Medical History

Is the child adopted? ( ) Yes ( ) No

What pregnancy was this child (1st, 2nd, etc.)?

Were there any problems with birth and delivery?( ) Yes ( ) No

If so please explain (Pre-natal care, gestation period, specific illnesses, accidents or injuries, or medications taken during pregnancy)

Approximate duration of Labor:

Caesarean section? ( ) Yes ( ) No

Breech presentation? ( ) Yes ( ) No

Were there any complications of delivery before, during or after?

Any infections, hemorrhage, cord around the neck?

Weight at birth length

Other information:

Is there any history of medical concerns?

Place an X by the following, if there has been a medical concern:

Vision / Accidents
Hearing / Injuries
Use of Hands / Surgeries
Use of Legs / Infections
Allergies / Enlarged Tonsils or Adenoids
Seizures / Feeding Problems
Frequent ear infections / Syndromes
If you placed an X by any items in this list, please explain:

Is your child currently taking any medication? ( ) Yes ( ) No

If so, please explain ______

Medication / Dosage / Frequency of Administration / Reason for Meds

Is there a history of speech and language problems or learning disabilities in other family members? ( ) Yes ( ) No

If yes, please explain:

DEVELOPMENTAL HISTORY

Neonatal: (first 30 days of life):

A.Cyanosis (blueness)( ) Yes ( ) No

B.Oxygen needed( ) Yes ( ) No

C.Jaundice( ) Yes ( ) No

D.Paralysis( ) Yes ( ) No

E.Infection( ) Yes ( ) No

F.Convulsions ( ) Yes ( ) No

G.Please tell us what details you remember about any of the above problems:

Was feeding a problem ( ) Yes ( ) No

If yes please describe:

Does your child have trouble: swallowing? ( ) Yes ( ) No

chewing? ( ) Yes ( ) No

does he/she drool?( ) Yes ( ) No

Have food allergies: ( ) Yes ( ) No

If yes please list:

Infancy through Preschool (0 through 5 years):

Did your child meet his/her developmental milestones (first word, first steps, solid foods, etc.) at the expected ages? ( ) Yes ( ) No

If no, please explain:

MEDICAL HISTORY

A.List any other specific illnesses not previously mentioned and at what age they occurred:

Description of Illness: / Age at which it occurred:

B.Has your child had any accidents or injuries?

Description of Injury: / Age at which it occurred:

HEARING, AUDITORY, BALANCE, COORDINATION & VISUAL PROCESSING:

Has your child ever had his/ her hearing tested? ( ) Yes ( ) No

If yes, please tell us when, and what the results were (e.g., within the normal range, below average, hearing impairment):

Have you ever noticed a problem with your child’s hearing? ( ) Yes ( ) No

Has anyone at school, or within your family ever expressed concerns about your child’s hearing?

( ) Yes ( ) No If yes, please explain:

Does your child demonstrate good balance skills?( ) Yes ( ) No

If there may be difficulty, please describe what you have seen:

How is your child’s coordination? ( ) good or normal for age ( ) a bit “clumsy” ( ) Other- please describe:

How is your child’s handwriting or coloring/ drawing skills?

( ) good or “normal” for age ( )Other- please describe:

Has your child had his/ her vision tested? ( ) Yes ( ) No

If yes, please tell us when, and what the results were:

Have you, your family, or teachers noticed your child having any difficulties with vision?

SPEECH AND LANGUAGE DEVELOPMENT

At what age did your child begin conversing?

Did speech or language ever stop or change significantly?

Is your child aware of his/her communication/reading/writing difficulty? ( ) Yes ( ) No

Have family members’ reactions to your child’s difficulty made him/her uncomfortable? ( ) Yes ( ) No ( )Non-applicable

Language(s) Is English the primary language used in the home?( ) Yes ( ) No

If your child speaks more than one language,please indicate the languages spoken and approximately how often is each language used:

Describe your child’s understanding and use of each language:

INTEREST INVENTORY

What are your child’s interests and favorite activities?

Does your child enjoy reading books? ( ) Yes ( ) No
Please describe:

Does your child experience difficulty spelling? ( ) Yes ( ) No
Please describe:

Does your child have any fears (e.g. such as stuffed animals, loud noises)

Are there any activities and/or toys that your child avoids or dislikes? If so, please describe:

SCHOOL AND INTERVENTION HISTORY

If child is in school, are there any concerns about academic performance (e.g., reading, writing, subject areas)? ( ) Yes ( ) No

If so, please explain

Has child received speech/reading/writing therapy previously?( ) Yes ( ) No

If so, where, and what were major goals?

Does your child receive special help in school? ( ) Yes ( ) No

If so, please explain

Is your child performing at grade level in school? ( ) Yes ( ) No

Are there any concerns that the teachers have expressed to you about your child’s performance?

Are there any concerns that you have about your child’s performance in school?

What are your child’s favorite subjects or activities in school?

What are your child’s least favorite, or most challenging, subjects and activities in school?

Overall, does your child enjoy going to school?( ) Yes ( ) No

Has the child been evaluated by other professionals (e.g., Occupational Therapy, Physical Therapy, Reading Resource Teacher, etc…)? ( ) Yes ( ) No

If so, who, and what specialty?

If your child has received special help at school or from other professionals, please bring any reports you might have to the diagnostic evaluation. In addition, copies of your child’s IEP (Individualized Education Plan) from the school, if you have them, would also be helpful to us in meeting your child’s needs.

FAMILY and SOCIAL INFORMATION

Is there anyone else in your family who has ever had a speech, language, reading, writing, or hearing problem? Please tell us about it:

Does your child attend aftercare or other outside activities?

Is your child involved in any sports or physical activity?

Is your child involved in Scouts or other clubs?

Is there anything else you wish to add that would help insure a positive testing experience for your child?

ADDITIONAL INFORMATION

What additional information would you like us to know about your child and his/ her speech and language or hearing problems?

Lastly, please let us know how you heard about Camp CHRONCLE:

We thank you for your time, and the care with which you filled out this form.

We appreciate your patronage, and look forward to helping you and your loved ones.-

If you have questions before your intake or diagnostic appointments, please contact the Rite Care Speech, Language and Hearing Clinic for Communicative Science & Disorders at (406)243-2377.

The Professionals, Student Trainees, and Staff of the RiteCare Speech Language, and Hearing Clinic

Camp CHRONICLE child case history form