Case History – Speech – Heidi Miller Speech

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Patient Name

First Last

Person filling out this form

First Last

Relationship to child

Today's Date

MM slash DD slash YYYY

Statement of the Problem

Describe in your own words what problem your child is having with speech, language, and/or hearing:

When was the problem first noticed and by whom?

List any other concerns you have regarding your child’s development:

Speech, Learning, and Hearing Development

Did your child make babbling or cooing sounds during the first 6 months of life?

Yes

At what age did your child say his or her first word?

What were your child’s first words?

Did your child keep adding words once he/she started to talk?

Yes

If no, please explain:

Do you consider your child quiet?

Yes

Did speech learning ever seem to stop for a period of time?

Yes

If yes, please explain:

Does your child talk/vocalize:

A lot

Occasionally

Never

Does your child prefer to:

Talk

Gesture

Talk and Gesture

Does your child most frequently use:

Sounds

Single words

2-word sentences

3-word sentences

More than 3-word sentences

List

Examples

Does your child make sounds incorrectly?

Yes

If yes, which ones?

Does your child hesitate, “get stuck,” repeat or stutter on sounds or words?

Yes

If yes, please describe:

Describe any recent changes in your child’s speech:

Can your child tell a simple story?

Yes

How well can your child be understood by the following individuals? Check the boxes that apply.

Parents

Always

Mostly

Sometimes

Rarely

Siblings

Always

Mostly

Sometimes

Rarely

Teachers

Always

Mostly

Sometimes

Rarely

Friends

Always

Mostly

Sometimes

Rarely

Strangers

Always

Mostly

Sometimes

Rarely

Does your child seem to understand what you say to him or her?

Yes

If no, please explain:

Does your child consistently answer to his/her name?

Yes

Does your child make appropriate eye contact with:

Adults

Other

Children

Does your child follow simple commands?

Yes

If yes, please explain:

Does your child ever have trouble remembering what you have told him or her?

Yes

If yes, please explain:

Does your child enjoy looking at books?

Yes

How often do you read to your child?

Developmental History

Is your child:

Biological

Foster

Adopted

Did the mother have medical problems during the pregnancy?

Yes

If yes, please describe, including medical attention:

Did the mother take any prescription and/or nonprescription medication during this pregnancy?

Yes

If yes, what kind(s):

Was your child full-term?

Yes

If no, what was the gestational age?

Was your child’s delivery normal?

Yes

If no, please explain:

Was your child’s delivery via caesarian?

Yes

If yes, please give the reason:

How long were the mother and child in the hospital?

You child’s weight at birth?

Any birth injuries?

What special medication attention or treatment did your child receive at birth, if any?

Was your baby:

Breast-fed

Bottle-fed

If breast-fed, for how long?

Any difficulties transitioning from breast to bottle?

Breast-fed

Bottle-fed

If yes, please describe:

What was your child’s age when weaned off the bottle?

Were there any feeding difficulties during infancy?

Yes

If yes, please describe:

What is your child’s present weight and percentile?

What age did your child begin puree foods (e.g., rice cereal, stage I jar foods)?

What age did your child begin soft chewable food?

What age did your child begin table food?

Did your child have difficulty transitioning to different food textures?

Yes

If yes, please describe:

Does your child have a limited diet due to “picky eating”?

Yes

If yes, please describe:

Does your child have any food allergies?

Yes

If yes, please list:

Does your child have any known gastrointestinal issues?

Yes

If yes, please explain:

Does your child:

Finger feed

Use a fork

Use a spoon

Use an open cup

Use a straw

Is adult assistance needed with feeding your child?

Yes

If yes, please explain:

Has your child ever choked on solid foods

Yes

Does your child cough on liquids?

Yes

Can your child chew well?

Yes

Does your child drool?

Yes

If yes, when?

Did your child use a pacifier?

Yes

If yes, age weaned off pacifier:

Does your child continue to mouth objects?

Yes

Did your child suck his/her thumb/fingers?

Yes

If yes, until when?

Does your child suck on his/her hair/clothing/blanket/etc?

Yes

If yes, what?

Does your child resist tooth brushing?

Yes

Does your child like taking a bath?

Yes

Does your child like swings?

Yes

Does your child like parties?

Yes

Does your child like rough housing?

Yes

Does your child prefer to primarily play:

Alone

With other children

With older children

With younger children

With adults

Is your child overly sensitive to loud sounds?

Yes

Is your child overly sensitive to bright lights?

Yes

Is your child overly sensitive to tags on clothing?

Yes

What age did your child do the following:

Sat Up

Crawled

Stood

Walked

Ran

Bladder trained

Bowl Trained

Night Trained

Which hand does your child use more frequently?

Left

Right

No preference

Family History

Are there any members of your immediate family that have been diagnosed with any of the following:

Learning Disability

Father

Mother

Sibling

Dyslexia

Father

Mother

Sibling

Speech and Language Delay/Disorder

Father

Mother

Sibling

Sensory Processing Disorder

Father

Mother

Sibling

Auditory Processing Disorder

Father

Mother

Sibling

ADD/ADHD

Father

Mother

Sibling

Autistic Spectrum Disorder/PDD

Father

Mother

Sibling

Other, please explain:

Medical History

Please list age, type of treatment, and/or number of recurrences next to those that apply:

Allergies

Age

Treatment

Recurrence

Asthma

Age

Treatment

Recurrence

Chronic Colds

Age

Treatment

Recurrence

Dental Problems

Age

Treatment

Recurrence

Ear Infections

Age

Treatment

Recurrence

Orthodontia

Age

Treatment

Recurrence

Seizures

Age

Treatment

Recurrence

Tonsillitis

Age

Treatment

Recurrence

Describe any other illnesses, accidents, injuries, and hospitalizations of your child (include child’s age):

If your child underwent any surgery, please describe (include date of surgery and surgeon’s name):

Is your child’s health:

Good

Fair

Poor

Is your child now under medical treatment or on medication?

Yes

If yes, please explain:

Describe any speech, language, hearing, OT, PT, psychological, special education services, tutoring that your child is receiving/has received.

Therapy One

Therapist, Frequency, Place (Private School), Group or Individual, Duration (E.G. Age 3-5)

Therapy Two

Therapist, Frequency, Place (Private School), Group or Individual, Duration (E.G. Age 3-5)

Therapy Three

Therapist, Frequency, Place (Private School), Group or Individual, Duration (E.G. Age 3-5)

Medical Examination History

Last Physical Exam:

Date

MM slash DD slash YYYY

Doctor

Results

Last Vision Test:

Date

MM slash DD slash YYYY

Doctor

Results

Last Hearing Test:

Date

MM slash DD slash YYYY

Doctor

Results

Did/does your child wear a hearing aid?

Yes

If yes, please explain:

Did/does your child wear glasses?

Yes

If yes, please explain:

Educational History

Does your child attend?

Daycare

Preschool

Kindergarten

Gradeschool

Name of school:

Grade Level:

In school, does your child do:

Average

Below Average

Above Average

What are your child’s best subjects?

Has your child repeated a grade?

Yes

If yes, which one(s)?

What is your impression of your child’s learning abilities?

What is your impression of your child’s social skills?

Does your child display any behavioral or attentional issues at school?

Yes

If yes, what might those issues be?