Audiology Clinic, 200 S. Jordan Avenue, Bloomington, IN 47405-7002
Child Case History
Date:______
Name:______Age:______Birth date:____-____-____ Sex: □ M □ F
Address:______Apt#:______City:______State______Zip______
Name of Parent(s) / Guardian (s):______
Mother’s Address: Father’s Address:
______
______
Occupation:______Occupation:______
Phone #: Phone #: Work: (_____)______Work: (_____)______
Home: (_____)______Home: (_____)______
Cell: ( ____)______Cell: (______)______
e-mail address: ______e-mail address: ______
Are languages other than English (including Sign Language) used at home? □ Yes □ No
What languages?______
Referral Source Information
Name:______
Relationship to child:______
Address:______
City:______State:______Zip:______Phone: (______)______
Reason for referral:______
______
______
Person completing questionnaire: ______
Statement of Concern
Describe your concerns regarding your child’s speech/language and/or hearing:______
______
______
When was this concern first noticed?______By Whom?______
What do you expect from this evaluation?______
______
______
Hearing History and Concerns
Did your child pass the newborn hearing screening? Yes_____ No _____
Has your child ever had a hearing evaluation? □ Yes □ No When?______
Where was the evaluation performed?______
By Whom?______
Results:______
Yes No
□ □ Do you feel your child hears well?
□ □ Has your child ever been exposed to a loud noise or explosion?
□ □ Has your child ever had an ear infection? Which ear?______
First Occurrence?______Last Occurrence?______Frequency?______
□ □ Does your child currently have or ever had draining ears (pus, blood, etc)?
□ □ Does your child ever complain of ear noises (tinnitus) such as ringing, buzzing, pulsing, etc?
In which ear is the sound heard?______
□ □ Does your child hear the same from day to day?
□ □ Does your child favor one ear? Which ear?______
□ □ Does your child respond to vibration caused by loud sounds (door slam, truck driving by,
airplane, radio in the car, boom box vibration, etc.)?
□ □ Does your child wear hearing aids? □ Right ear □ Left ear □ Binaural
Make and Model:______
How long as he/she worn hearing aids?______
How many hours per day does your child were the hearing aids?______
Speech-Language History and Concerns
Did your child begin to babble or talk and then stop? □ Yes □ No
Please explain:______
______
Please check all the means of communication your child currently uses:
□ Speech □ Vocalizations □ Bodily Gestures □ Spoken Yes / No □ Facial Gestures
□ Gestural Yes / No □ Take to item physically □ Hand signs □ Pointing
Please list adaptive equipment currently used:______
______
At what age did he/she say his/her first word?______
Please give examples of his/her first words:______
Approximately how many words did your child use at 18 months______? 24 months?______
At what age did your child say his/her first sentence?______
Please give examples of his/her first sentences:______
______
______
Please give an example of typical sentences your child currently uses:______
______
______
How often does your child use speech? □ Frequently □ Sometimes □ Rarely
How does your child make his/her needs known? ______
Does your child use gestures? □ Yes □ No Please give examples:______
______
What does your child use the most? □ Gestures □ Sounds □ One or Two Words □ Phrases
□ Complete Sentences
Estimate the percentage of time that your child is understood by:
___ Unfamiliar listeners ___Parents ___ Other adults ___ Siblings ___Friends
How well does your child understand what is said to him/her?______
Please indicate your child’s current level of understanding: ( check all that apply)
□ Understands Gestures □ Does Notunderstand spoken words □ Understands single words
□ Understand simple sentences □ Understands 2 and 3 part commands □ Understands conversation
Do you think your child is aware of his/her communication difference? □ Yes □ No □ Unsure
If so please describe how the child shows awareness:______
______
______
______
Provide any other information about your child’s communication that is of concern to you:______
______
______
______
What have immediate family and/or relatives done to help your child overcome his/her communication delay?______
______
______
______
Has this helped?______
What do you think caused this communication difference?______
______
______
Please provide any additional information you feel will help us in understanding your child and his/her present communication ability:______
______
______
Prenatal (pregnancy), Birth and Development
Mother’s age when child was born:______Father’s age when child was born:______
Length of pregnancy is weeks:______
Prenatal:
Yes No
□ □ Did the mother experience bleeding during pregnancy?
□ □ Did the mother have measles during pregnancy?
□ □ Did the mother have high blood pressure during pregnancy?
□ □ Did the mother experience leaking of the membranes during pregnancy?
□ □ Were there complications during this pregnancy (anemia, dehydration, diabetes,
kidney infection, severe nausea, toxemia, accidents, etc.)? Please describe
complication(s) and treatment(s):______
______
□ □ Were prescription/non-prescription drugs (including alcohol) taken during pregnancy?
If so please list:______
Birth:
Yes No
□ □Did the mother have a normal delivery with this child?
□ □Breech delivery?
□ □Caesarean Section delivery?
□ □Were there birth injuries? Please describe:______
□ □Breathing difficulties? (e.g., blue baby, required oxygen, stopped breathing, etc.)
Please describe:______
□ □Special instruments used during delivery? Please describe:______
□ □Was the baby jaundice at birth?
□ □Rh incompatible?
Birth weight: _____lbs. _____oz. 1 minute Apgar______5 minute Apgar______
How long was your infants stay in the hospital following birth? ______□ day(s) □ week(s) □ month(s)
Were there any complications immediately following birth or during the first two weeks of your infant’s life
(feeding, seizures, sleeping, swallowing, hospitalizations, etc.)?______
______
______
Development (give age when first occurred):
______Held head up______Reached for an object
______Sat up unsupported ______Crawled
______Stood alone ______Walked alone
______Fed self with spoon______Bladder trained
______Bowel trained______Undressed self
______Dressed self
What motor and/or self-help development concerns do you have for your child:______
______
Would you describe your child’s coordination as: □ Good □ Fair □ Poor
Please explain:______
______
______
______
Child’s Medical History
Pediatrician/Doctor:______
Address:______City:______State:______Zip:______
Phone: (_____)______
Please check all conditions your child presently has or has had:
□allergies
□asthma
□blood disease
□chicken pox
□convulsions
□crossed eyes
□dental problems
□diphtheria
□encephalitis
□croup
□epilepsy/seizures
□apraxia
□headaches
□head injury
□dysarthria
□heart problems
□high fevers
□influenza
□measles
□meningitis
□mumps
□muscle disorder
□nerve disorder
□traumatic brain injury
□pneumonia
□dysplasia
□polio
□rheumatic fever
□brochopulmonary
□whooping cough
□stroke
□cerebral palsy
□tracheostomy
□RSV
□failure to thrive
□CHARGE association
□CMV (Cytomegalovirus)
□HIV
□ feeding or swallowing problems
□gastro esophageal reflux
Visual
1. Does your child wear glasses? □Yes□No
2. Does your child have any visual problems? □Yes□No
If so please describe:______
______
______
3. Date of most recent vision testing:______
4. Where was the testing done?______
5. By whom was the testing performed?______
Ear, Nose and Throat
Please check all the conditions that your child currently has or has had:
□chronic coughs/colds□hoarse voice□difficulty swallowing□tonsillitis
□tonsillectomy□adenoidectomy□adenoidectomy□tongue deformity
□jaw deformity□cleft palate/lip□speech problem□ear deformity
□dizziness□pressure equalizationtubes□excessive wax in ears
Please list any medications your child is currently taking:______
______
If your child has been seen by a medical specialist, hospital, clinic, agency, etc., please list below:
Agency/SpecialistDateWhat was done? Results/Recommendation
Name______
Address______
______
Phone #:______
Name______
Address______
______
Phone #:______
Name______
Address______
______
Phone #:______
Educational History
Does your child attend:□daycare□kindergarten□school
□other______
Name of school______Current Grade______
Address______Phone #:______
City______County______State______Zip______
Teacher’s Name______
Speech-Language Pathologist’s Name______
Principal’s Name______
Previous Schools Attended
Name of School:Address:Dates Attended:
1.
2.
3.
Current grades for: Reading______Language______Spelling______Math______
Does your child have a current IEP?□Yes□No
If yes, please have the school send a copy to the Speech and Hearing Clinic, Attn: Audiology.
Cognitive History
Psychological Evaluation Completed? □Yes□No
If yes, please provide the Speech and Hearing Clinic with a copy of the Evaluation Report.
Date of most recent test______Where tested?______
By Whom?______Test Results______
______
Home and Family
Please list any other family member(s) who have a hearing loss (before age 50) or speech/language or learning difficulties (brothers, sisters, mother, father, and extended family such as grandparents, cousins, etc.)
Name:DOB:Age:Sex:Communication/Relation to
Learning Concern: this child:
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Please list everyone who lives with this child:
Name:Age:Sex:Relationship to child:
▪
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List of significant activities, interests, events, hobbies, favorite toys, etc.
▪
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This assessment cannot proceed without the signature of the legal guardian.
Signature of parent/guardian:______
Date:______
Please bring completed forms with you to your child’s appointment. Thank you.