Department of Speech and Hearing Science

CASE HISTORY FORM

Form completed by: Click here to enter text. / Date Completed: Click here to enter text.
Relationship to Child: Click here to enter text.
MY FAMILY
Child’s Name: Click here to enter text. / Nickname(s): Click here to enter text.
Child’s Date of Birth: Click here to enter text. / Chronological Age: Click here to enter text.
Gender: ☐Male ☐Female
Mother’s Name: Click here to enter text. / Father’s Name: Click here to enter text.
Phone Number: Click here to enter text. / Phone Number: Click here to enter text.
Email: Click here to enter text. / Email: Click here to enter text.
Address: Click here to enter text.
Please list all family members or other persons who live in the home and/or contribute to the child’s care.
Name:
Home Address:
Email:
Work Phone #: / Relationship to child:
Home Phone:
Place of Employment:
Lives with Child: ☐Yes ☐No
Name:
Home Address:
Email:
Work Phone #: / Relationship to child:
Home Phone:
Place of Employment:
Lives with Child: ☐Yes ☐No
Name:
Home Address:
Email:
Work Phone #: / Relationship to child:
Home Phone:
Place of Employment:
Lives with Child: ☐Yes ☐No
Name:
Home Address:
Email:
Work Phone #: / Relationship to child:
Home Phone:
Place of Employment:
Lives with Child: ☐Yes ☐No
Child’s Racial/Ethnic Background:
☐African-American / ☐Asian Pacific / ☐Caucasian / ☐Hispanic
☐Native American / ☐One or more races / ☐Other: Click here to enter text.
Referred By:
☐Pediatrician / ☐Developmental Pediatrician / ☐Speech-Language Pathologist / ☐Occupational Therapist
☐Physical therapist / ☐Psychologist / ☐School / ☐Family Member/Friend
☐Word of Mouth / ☐Other: Click here to enter text.
Please describe the concerns regarding your child’s development:
Click here to enter text.
How long have you been concerned: Click here to enter text.
Has your child been diagnosed with any of the following conditions? Check all that apply
ADHD / ☐ /
Articulation/phonology / ☐ /
Autism spectrum disorder (PDD, autism, aspergers) / ☐ /
Behavior problems / ☐ /
Genetic disorders / ☐ /
Hearing disorder / ☐ /
Expressive and/or receptive language disorder / ☐ /
Learning disorder / ☐ /
Oral motor feeding / ☐ /
Sensory integration difficulties / ☐ /
Stuttering / ☐ /
Other: Click here to enter text. / ☐ /
If any checks were made, please describe the nature of the diagnosis, and by whom & when it was made:
Click here to enter text.
BIRTH HISTORY
Please describe any health problems during pregnancy:
Click here to enter text.
Please describe any drug use, alcohol use, x-ray or any trauma during pregnancy:
Click here to enter text.
Please describe exposure to any illness or infectious disease:
Click here to enter text.
CHILD’S BIRTH HISTORY
Born at Click here to enter text. weeks / Birthweight: Click here to enter text.
Please describe any complications during birth:
Click here to enter text.
Was your child in the neonatal intensive care unit (NICU): ☐Yes ☐NO
If Yes, Please explain in detail: Click here to enter text.
Were the following present at or immediately after birth?
☐Breathing difficulties / ☐Required Oxygen / ☐Jaundice / ☐Infections (e.g., meningitis)
☐Cleft lip/palate / ☐Seizures / ☐Physical abnormalities / ☐Medications
CHILD’S HEALTH HISTORY
Check all that apply
☐Ear Infections: / ☐Rarely / ☐Occasionally / ☐Frequently / ☐Constantly
Age range of occurrence: Click here to enter text.
Most recent episode: Click here to enter text.
Infections resolve quickly? ☐Yes ☐No
Typical treatment: Click here to enter text.
Pressure Equalization Tubes (P.E. tubes placed? ☐Yes ☐No
P.E. tubes in place now? ☐Yes ☐No
☐Allergies (please describe): Click here to enter text.
☐Frequent/chronic colds
☐Measles
☐Mumps
☐Chicken Pox
☐Thyroid condition
☐Head injury
☐Syndrome (please describe): Click here to enter text.
☐Other illnesses, conditions, injuries (please describe): Click here to enter text.
Are child’s immunizations current? / ☐Yes ☐No
Please list any medications your child is taking: Click here to enter text.
Does child have vision difficulties (e.g., wear glasses)? ☐Yes ☐No
If yes, please describe: Click here to enter text.
Has child had a hearing test? ☐Yes ☐No
If yes, what were the results: Click here to enter text.
Please describe any hospitalizations: Click here to enter text.
GENERAL DEVELOPMENT
Please indicate which column best describes your child’s current performance relative to his/her chronological age:
Perceptual/Fine Motor: / Excellent / Good / Fair / Poor / Unknown
Hand/eye coordination (e.g., stacking blocks, coloring)
Which hand does your child prefer / ☐Right ☐Left ☐Either
Gross Motor
Motor coordination and balance (e.g., walking, hopping, running)
Social/Emotional/Play: / Excellent / Good / Fair / Poor / Unknown
Self-esteem
General behavior at home
General behavior away from home
Ability to separate from familiar adults
Ability to play with other children
Ability to play appropriately with toys/games
Ability to respond appropriately to discipline
Ability to control frustration
Cognition: / Excellent / Good / Fair / Poor / Unknown
Ability to keep attention on an activity
Typically attends to an activity for __ min.
Ability to maintain appropriate activity level
Ability to think before acting (e.g. does not behave impulsively)
Ability to sit still (e.g. not fidgety/restless
Ability to problem solve
Ability to remember familiar faces
Ability to follow simple instructions
Ability to follow multiple instructions
Knowledge of space/time/quantity concepts
Ability to identify letter-sound correspondence
Language Comprehension and Production: / Excellent / Good / Fair / Poor / Unknown
Ability to converse with adults
Ability to converse with children
Takes appropriate turns in conversation
Ability to maintain the topic of conversation
Ability to get point across when talking
Ability to maintain eye contact while talking
Ability to use proper sentence structure
Ability to understand questions
Ability to recite familiar nursery rhymes
Ability to tell or retell a story
FINE MOTOR & SENSORY INTEGRATION
Does your child like/tolerate being messy / ☐Yes / ☐No
Does your child enjoy haircuts / ☐Yes / ☐No
Does your child like to be touched, hugged, hand held / ☐Yes / ☐No
Does your child react negatively to loud noises / ☐Yes / ☐No
GROSS MOTOR AND LARGE MUSCLE MOVEMENT
At what age did your child
Crawl: Click here to enter text. / Sat alone: Click here to enter text. / Walked: Click here to enter text.
Do you believe these skills were obtained at the correct age?
COMMUNICATION SKILLS
At what age did your child
Babble: Click here to enter text. / Used Single words: Click here to enter text. / Combined words: Click here to enter text.
Please provide examples of your child’s words or phrases: Click here to enter text.
What percentage of the time do familiar listeners understand me / Click here to enter text.%
Do unfamiliar listeners understand me / Click here to enter text.%
Describe the child’s primary mode of communication: Click here to enter text.
HEARING
Do you have concerns about your child’s hearing? ☐Yes ☐No
Does your child
Respond to various sounds in the environment / ☐Yes / ☐No
Startle to loud noises / ☐Yes / ☐No
Enjoy toys that make noise / ☐Yes / ☐No
Locate the source of sounds / ☐Yes / ☐No
Respond to face-to-face speech / ☐Yes / ☐No
Respond to speech from a distance / ☐Yes / ☐No
Frequently ask for repetition / ☐Yes / ☐No
Appear to be a good listener / ☐Yes / ☐No
Has your child been seen by an ear physician / ☐Yes / ☐No
If yes, please describe: Click here to enter text.
Has your child had a hearing screening or hearing test? / ☐Yes / ☐No
If yes, what were the results, at what age was the child when the test was administered? Click here to enter text.
Does your child have any hearing loss? / ☐Yes / ☐No
If yes, please describe: Click here to enter text.
Does your child wear hearing aids or use a listening system / ☐Yes / ☐No
If yes, please describe: Click here to enter text.
SELF-CARE
Feeding
How was your child fed as an infant? / ☐Bottle / ☐Breast / ☐Other: Click here to enter text.
Describe any feeding problems at birth: Click here to enter text.
Does your child have gag or biting reflexes? / ☐Yes / ☐No
Does your child have difficulty with drooling / ☐Yes / ☐No
Have difficulties with textures of food? / ☐Yes / ☐No
Have difficulty with temperature of foods or drinks / ☐Yes / ☐No
Like having his/her teeth brush / ☐Yes / ☐No
Have food allergies / ☐Yes / ☐No
If yes, please describe: Click here to enter text.
Finger feed themselves / ☐Yes / ☐No
Feed themselves with a spoon with many spills / ☐Yes / ☐No
Drink from a bottle / ☐Yes / ☐No
Drink from a sippy cup / ☐Yes / ☐No
Drink from a straw / ☐Yes / ☐No
Drink from a cup independently / ☐Yes / ☐No
What are mealtimes like at your home? Click here to enter text.
Does your child have a favorite food? Click here to enter text.
Toileting
Does your child wear diapers? / ☐Yes / ☐No
Is your child potty trained? / ☐Yes / ☐No
Are you and your child working on potty training? / ☐Yes / ☐No
Does your child use the bathroom independently? / ☐Yes / ☐No
Dressing
Does your child take off his/her own shoes and socks? / ☐Yes / ☐No
Do you dress your child? / ☐Yes / ☐No
Can your child dress himself/herself? / ☐Yes / ☐No
Does your child button, zip and unzip? / ☐Yes / ☐No
Does your child choose what to wear? / ☐Yes / ☐No
HELP US GET TO KNOW YOUR CHILD MORE
What is bedtime like at your home? Click here to enter text.
Describe how well your child sleeps at naptime and at night: Click here to enter text.
How does your child interact with familiar adults, new adults, & other children?Click here to enter text.
Does your child have a favorite toy or person to interact with?Click here to enter text.
How does your child let you know what he/she wants or needs?Click here to enter text.
What activities does your child enjoy indoors and outsides?Click here to enter text.
When hurt or scared, is your child easily comforted? How? Does your child have any specific fears? Click here to enter text.
How do you discipline your child? Click here to enter text.
What would make life easier for you or your child? Click here to enter text.
What is the most frustrating aspect you are currently facing? Click here to enter text.
What do you like most about your child? Click here to enter text.
How would you describe your child’s personality? Click here to enter text.
What is a typical day like at your home? Click here to enter text.
What times of the day are better or worse for your child? Click here to enter text.

Department of Speech and Hearing Science

Coor Hall, P.O. Box 870102, Tempe, AZ 85287
Phone: 480.965.2373 | Fax: 480.965.0076