CASE HISTORY FORM

I. Demographic Data
Name:
Medical Diagnosis:
Date of Birth:
Date of SP Initial Evaluation:
Chronological Age:
Address:
Telephone/ Cellphone Number:
E-mail address:
Referring Doctor:
Contact Number of Referring Doctor
Hospital/ Clinic:
Name of Informant (your name):
II. Speech and Language History
1 What characteristic of the child made you opt for a developmental
pediatrician consult and speech therapy?
Ano ang inyong napansin sa bata kaya kayo pumunta para sa doktor
at speech therapy?
2 What date was the child diagnosed?
Anong petsa na-diagnose ang bata ng kanyang kondisyon?
3 What is/ are the child’s primary means of communication? (gestures,
voice, words, pictures, etc.)
Ano ang ginagamit na pamamaraan ng bata para makipag usap?
4 What is the first/ primary language of the child?
Ano ang pangunahing wika na natutunan ng bata?
5 How much does the caregiver understand the child’s speech? (In
terms of percent)
Sa sinasabi ng bata, ilang porsyento ang naiintindihan ng mga
magulang/ tagapag-alaga niya?
6 How many percent do strangers/ neighbors understand?
Ilang porsyento naman ang naiintindihan ng ibang tao/ mga
kapitbahay?
7 Regarding what others say to the child, how many percent do you
think the child can understand?
Ilang porsyento naman sa sinasabi sa kanya, naiintindihan ng bata?
8 What performance do you expect of the child after 1 year in therapy?
Ano ang inyong ine-expect na performance ng bata matapos ang 1
taon?
9 End goal for the child in therapy?
Ano ang inyong gustong maabot na kakayahan ng bata sa
pagtatapos ng therapy?
10 Number of hours spent talking to the child per day
11 What managements were recommended by the developmental
pediatrician? (e.g. speech therapy, physical therapy, occupational
therapy, SPED sessions, etc.)
12 Who is the child’s primary caregiver?
Sino ang pangunahing tagapag-alaga ng bata?
13 Who is the child’s primary communicative partner?
Sino ang pangunahing kumakausap sa bata?
14 What age was the child able to do the following?/ ​Anong edad nagawa ng bata ang mga sumusunod?
Skills Age Acquired
Turning to source of sound
Responding to own name
Recognizing names of familiar people and objects
Following simple commands Age:__________
Example of command:______________
Answering questions
Cooing (googoogoo)
Babbling (babababa/ dadada)
Imitated adult sounds (intonation)
First Word (specific) Age:___________
First word:____________________
2-word utterances Age:______________
Example:_____________________

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 Phrases/ Sentences Age:________________
Example (Give 2):_________________
Example:________________________

III. Developmental History

1 Age of parents at child’s birth Mother:____________ Father:____________
2 Birth-order/ ​Pang-ilan na anak ang bata?
3 Months of pregnancy Duration of Labor:
4 What type of delivery? (Normal, Caesarean, etc.) Hospital:
5 Birth weight
6 Did the child undergo newborn screening?
7 What was the result of the newborn screening?
8 Are there complications that happened during pregnancy? Please
explain in the blank provided.
9 Complications after birth of the child?
10 What age was the child able to do the following?
Milestones Age Achieved
Held head erect while lying on stomach
Rolled over alone
Sat alone unsupported
Crawled
Stood alone
Walked unaided
Fed self with spoon
Had first tooth
Bladder trained
Bowel trained
Completely toilet trained

IV. Medical History

1 What major illnesses did the child have in the
past?
2 What medications (and what dosage and Medication: Dosage Freq.(#of times a day)
frequency) did she take? 1
2
3
4
5
6
7
8
9
3 Food supplements/ Vitamins? Please
enumerate.
4 What tests have the child undergone? (MRI, Test: Result:
hearing test, etc.) What were the results?
5 What are the allergies/ allergy of the child? (if
any), please specify medications taken

V. School History
1 Child’s school/s. Specify the year he/she School Name Grade Year Curriculum (regular/ SPED/ etc.)
started and the curriculum and level he/ she is 1
in. 2
3
4
5
2 How many students are in her/his class?
3 What are the activities/ subjects they do/study
at school?

4 What are the child’s feelings towards attending

school?
5 Describe the child’s performance at school
compared to her classmates? Grades?

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6 Teacher’s comments on the child?

7 Behavior at school?

8 Describe the child’s relationship with his/her

classmates.
9 Subject/ activity the child is GOOD at.
10 Subject/ activity the child has difficulty in.

VI. Therapy History: Please specify the treatment, year started-year ended, goals, therapist, and clinic
Therapy (SP/PT/OT/SPED, etc.) Year started Ended Goals (REQUIRED) Therapist Clinic

VII. Family and Social History

1 Name of parents and Occupation Mother’s name: Occupation:
Father’s name: Occupation
2 Siblings’ name Age Occupation:
1
2
3
4
5

3 Other family members/ people the child is living with Name Age Occupation: Relationship w/ child
1
2
3
4
5

4 Are there family members/ relatives who had difficulty

speaking/ had special conditions?
5 What is the child’s relationship with that family member Relationship:___________
(uncle, aunt, sibling, etc.)? What side? (mother’s side/ Side:_____________
father’s side)
6 Child’s favorite activities

7 Concerns on the child’s behavior?

8 Mode of discipline
9 Is this mode of discipline effective? How so?

10 Specify the child’s daily schedule (school days, if applicable) below:

Time Activity
6:00-7:00 AM
7:00-8:00 AM
8:00-9:00 AM
9:00-10:00 AM
10:00-11:00 AM
11:00 AM-12:00 PM
12:00-1:00 PM

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1:00-2:00 PM
2:00-3:00 PM
3:00-4:00 PM
4:00-5:00 PM
5:00-6:00 PM
6:00-7:00 PM
7:00-8:00 PM
8:00 PM-

Feeding History:
Consistencies:
-Thin Liquid:
-Thick Liquid:
-Soft Solid:
-Hard solid:_______
-Puree:__________
-Mashed:___________
-Chewy Solid:__________

Feeding length:

Dependency:

Behavior during feeding:

Reflexes/ hyper/hyposensitivity:

Daily Diet:
Breakfast
Lunch
Dinner
Current Weight:

Current Height:

Others:

I agree to the documentation through the video/audio recording of the evaluation session to be used for evaluation and intervention
purposes only.

Date:______________________

Parent/ Caregiver: __________________________

(Signature over printed name)

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