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Elena Caffentzis, M.S., CCC-SLP, BRS-FD
Speech Language Pathologist
Phone: 914.907.7231 Email:
Today’s date:
PEDIATRIC CASE HISTORY FORM
Child’s Name:______
Address:______
______
Phone:______
Date of Birth:______
Referred By:______School:______Insurance: ______Teacher’s Name:______
Grade:______
Pediatrician (name & address):______
Person Completing Form:______
Relationship to Child:______
SPEECH AND LANGUAGE HISTORY:
(1) Please describe your child’s current speech and language skills and any concerns you have.
(2) What was the approximate age that your child began having difficulty with fluency?
(3) Who first noticed or mentioned stuttering?
(4) Were there any precipitating factors that you suspect may have been associated with the onset of disfluency (i.e. birth of a sibling, illness, geographic move, divorce)?
(5) Has your child been evaluated for speech by another professional? If yes, what recommendations were you given?
(6) How did you and other family members react to the onset of the disfluencies?
(7) Please describe the initial disfluency patterns (check all that apply):
_____ repetitions of the first letter (b-b-boy)
_____ repetitions of the whole word (boy-boy-boy)
_____repetitions of part of the word (ca-ca-cat)
_____prolongations of sounds (mmmmmom)
_____silent blocks before speaking (-----boy)
_____fillers (um, well, uh)
_____changing words or starting over
_____other
(8) Please describe any initial physical behaviors observed during speech (check all that apply):
_____eye blinking _____squeezing eyes shut
_____head nodding _____looking away
_____hand or foot movement _____tension
_____difficulty breathing _____other
(9) At the time that your child began having difficulty, what was his/her reaction (i.e. awareness, frustration, shame, indifference, avoidance)?
(10) Please describe your child’s current disfluency patterns (check all that apply):
_____ repetitions of the first letter (b-b-boy)
_____ repetitions of the whole word (boy-boy-boy)
_____repetitions of part of the word (ca-ca-cat)
_____prolongations of sounds (mmmmmom)
_____silent blocks before speaking (-----boy)
_____fillers (um, well, uh)
_____changing words or starting over
_____other
(11) Please describe any current physical behaviors observed during speech (check all that apply):
_____eye blinking _____squeezing eyes shut
_____head nodding _____looking away
_____hand or foot movement _____tension
_____difficulty breathing _____other
(12) What is your child’s current reaction to disfluencies (i.e. awareness, frustration, shame, indifference, avoidance)?
(13) Were there any periods (days, weeks, months) when stuttering either increased or decreased?
(14) List any situations (i.e. people, places, times) when your child’s disfluencies increase or decrease.
(15) How do you and your family now respond to your child’s disfluent speech?
(16) Do you feel that your child is aware and/or concerned about his/her speech? What caused you to have this belief?
(17) How concerned are you about your child’s disfluent speech? How concerned is your child?
(18) Would you describe your child’s speech difficulty as mild, moderate or severe?
(19) What do you hope to gain from this evaluation?
(20) Are there any other speech and language concerns?
(21) At what age did your child:
_____babble (e.g. 6 months, 10 months, etc.)
_____jargon
_____say first words
_____2-3 word combinations
_____form sentences
MEDICAL, DEVELOPMENTAL, AND FAMILY HISTORY
(1) Please describe pregnancy and birth history (i.e. complications, type of delivery, prematurity, etc.).
(2) Please describe any developmental problems experienced during infancy or early childhood (i.e. late in walking, feeding issues, delayed language).
(3) List all illnesses, injuries, operations:
Date / Complications / Treatment / Physician(4) Please note any current physical disabilities.
(5) Has your child been tested for vision?_____ results?
hearing?_____ results?
(6) Has your child had a history of ear infections? If yes, give number of times per year and ages.
(7) What hand does your child use most often?
_____right _____left _____both
(8) Does your child take any medications?
EDUCATIONAL AND SOCIAL HISTORY
(1) Present school placement.
(2) How old was your child when he/she started school?
(3) Does your child spend time in a regular classroom?
(4) Has your child ever had a 766 CORE evaluation?
FAMILY HISTORY
Name / Age / Highest grade completed / Occupation / Handednessmother
father
Children / Name / Age / Grade / Handedness
1
2
3
Please complete and return this form at our first meeting. Please bring copies of any previous evaluations at that time. Thank you for your cooperation with this questionnaire.