SPEECH AND LANGUAGE PATHOLOGY CASE HISTORY

The purpose of this form is to gather data from the child and/or the child’s family so we (i.e. patient, his/her family,
and I—as the speech therapist) can collaboratively create a plan that will promote functional communication.
Please take your time in answering this questionnaire ☺

GENERAL INFORMATION

Child’s Name: _______________________________ Child’s Nickname: __________________ Birthdate: ________________________________

Child’s Physician: ________________________________________________________ Age: ___________________ Gender: __ Male __ Female
Address: _________________________________________________________________________________________________________________________
Mother’s Name: _____________________________________________________________ Contact Number: _______________________________
Father’s Name: ______________________________________________________________ Contact Number: _______________________________
Referred by: _________________________________________________________________ Child’s Diagnosis: _______________________________
Language(s) used at home: ____________________________________________________________________________________________________
Child’s Allergies: ________________________________________________________________________________________________________________
Medication: ______________________________________________________________________________________________________________________
Primary Concerns: Why did you bring your child for an evaluation? Please list the difficulties that your child is
having that you would like to address in Speech and Language therapy.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Goal after therapy: What specific Speech and Language skills would you like your child to achieve in therapy?
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

FAMILY BACKGROUND

Who is currently living in your home?

Name Relationship Age

Is there a family history of Speech, Language, or Hearing Difficulties? _____________________________________________________

PREGNANCY AND BIRTH HISTORY

Maternal / Paternal History

Maternal History (Mother) Paternal History (Father)
( ) Diabetes Mellitus ( ) Diabetes Mellitus
( ) Cardiopulmonary Diseases ( ) Cardiopulmonary Diseases
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 ( ) Hypertension ( ) Hypertension
( ) Hypersensitivity Reaction ( ) Hypersensitivity Reaction
( ) Asthma ( ) Asthma
Other ________________________________________________________ Other ________________________________________________________

Prenatal History (BEFORE Birth)

Mother’s health DURING pregnancy: __________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Medications the mother took DURING pregnancy: __________________________________________________________________________
Any miscarriages? Did it precede or follow pregnancy with your child? ___________________________________________________
Number of pregnancy: ______ Number of successful pregnancy: ______ How many are full term? _____ How many are
pre-term? ____ Mother’s attitude toward pregnancy: ________________________________________________________________________
Mother’s prenatal care: _________________________________________________________________________________________________________

Perinatal History (DURING Birth)

Age of mother during birth: ____ Hospital/place where the mother gave birth: ___________________________________________
Length of pregnancy (month or weeks): ______________ Type of delivery: ___________________________________________________
Weight of your child at birth: _______________ How was the mother’s general health during pregnancy? _________________
____________________________________________________________________________________________________________________________________

CHILD’S MEDICAL AND INTERVETION HISTORY

Has your child had any of the following? (Please check all that apply)
( ) Tonsils/Adenoids removed ( ) Snoring/Mouth breathing ( ) Vision problem
( ) Frequent ear infections/Cold ( ) Sleeping difficulty ( ) Nursing/Feeding difficulties
( ) Allergies/Anaphylaxis ( ) High fevers ( ) Unusual eating habits
( ) Middle ear tubes ( ) Seizures ( ) Thumb/Finger sucking habits
( ) Hearing problem ( ) Head injury ( ) Serious illness/Accident
( ) Asthma Other: _____________________________________________________________________________
Has your child had any surgeries? _____________________________________________________________________________________________
Is your child up to date on his/her vaccines? _________________________________________________________________________________
Allergies: _________________________________________________________________________________________________________________________
Does your child take any medications? Please list all medications taken regularly (include the schedule) _____________
____________________________________________________________________________________________________________________________________
Have there been any negative reactions to medications? ___________________________________________________________________
Are there any other precautions we should know about that are not described above? _________________________________
____________________________________________________________________________________________________________________________________

Has your child been seen by:

Professional Name Year Attended Schedule

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 Speech Language Pathologist

Occupational Therapist

Physical Therapist

Special Education

Audiologist or had a hearing test

Pediatrician

Ear, Nose, Throat (ENT) Doctor

*other*

DEVELOPMENTAL HISTORY

Provide the approximate age at which your child began to do the following activities:
Held head erect while lying on stomach ______________ Fed self with spoon ______________
Rolled over alone ______________ Had first tooth ______________
Sat alone unsupported ______________ Completely toilet trained ______________
Crawled ______________ Use single words (e.g. no, mama, dog) ______________
Stood alone ______________ Combine words (e.g. me go, daddy shoe) ______________
Walked unaided ______________ Engage in conversation ______________
Does your child have/show any of the following behaviors: (Please check all that apply)
( ) Demands attention ( ) Lacks confidence ( ) Unusual stress at home ( ) Underactive
( ) Short attention span ( ) Withdrawn ( ) Confused in noisy places ( ) Hyperactive
( ) Nervous or sensitive ( ) Tires easily ( ) Talks excessively ( ) Impulsive
( ) Easily frustrated ( ) Prefers to play alone ( ) Difficulty following ( ) Makes inappropriate
directions statements/behavior
( ) Sensitive to loud noise ( ) Lack motivation
( ) Aggressive ( ) Easily distracted ( ) Easily distracted ( ) Separation Difficulties
Other: ____________________________________________________________________________________________________________________________

CURRENT SPEECH-LANGUAGE SKILLS

Vocabulary
Yes No +/- Skill Exemplars

Point to nouns (e.g. objects, animals, food, people)

Name nouns (e.g. “cup”, “dog”, “apple”, “mama”)

Count from 1 to 3 or 1 to 10

Auditory Processing

Speech and Language | Case History Form | TheraPlay

 Yes No +/- Skill Exemplars

Follow simple instructions (e.g. “get the __”)

Responds to name when called

Responds to WH- questions (e.g. who, where, when, why)

Responds to YES/NO questions

Listening
Yes No +/- Skill Exemplars

Remember things people say

Repeat what people say

Looks at people when talking or listening

Understand facial expressions, gestures, or body language

Speaking
Yes No +/- Skill Exemplars

Asks for help when needed

Asks WH questions (e.g. who, where, when, why)

Describe things to people

Tells stories or talking about things that happened

Put events in the right order when telling stories

Uses good grammar when talking

Use complete sentences when talking

Talks in short, choppy sentences

Expands an answer or provide details when talking

Talks with a group of people

EDUCATIONAL AND SOCIAL INFORMATION

School presently attending: ____________________________________________________________________________________________________

Grade Level: __________________ Teacher: _________________________________ Any grades repeated? _________ skipped? ________
How does your child feel about school and his/her teachers? ______________________________________________________________
Does your child have serious difficulty in any subject? ___________________ Excel in any subject? __________________________
Does your child have opportunities to play with other children? If so, how often and where? __________________________
______________________ Does your child play well with friends/brothers/sisters/cousins? __________________________________
Please describe the activities that your child enjoys doing or playing: _____________________________________________________
____________________________________________________________________________________________________________________________________

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 ADDITIONAL COMMENTS/OTHER IMPORTANT INFORMATION

Is there any other information you feel would help us evaluate your child or doing our intervention? _________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Are there any questions you would like to ask? ______________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Thank you for your time and attention in completing this history form!
I, _________________________ , hereby acknowledge that the information above are true to the best of
my knowledge. I, therefore, grant Ms. Hanna Colita, the speech therapist, the right to keep such
information for analysis.

Please return your complete case history form 1 week after the Initial Evaluation to:
TheraPlay Pediatric Clinic

For questions, clarifications, comments, or concerns regarding the contents of this report, please
do not hesitate to send a text/email to:

Clinician Name: Hanna Colita

Clinician Mobile #: 09217085069
Clinician Email: hcolita.slp@gmail.com

Speech and Language | Case History Form | TheraPlay