Speech,

Language, and Hearing Case History Form

I. Identifying Information

Child’s Name (Pangalan ng bata): __________________________________________

Nickname: _______________
Date of birth (Kapanganakan): __________________________
Age (Taon/Gulang): ___________ Nationality: __________________
Sex (Kasarian): ______________
Primary Language/s (Pangunahing Wika): _________________________

To be filled out by the examiner/clinician (Pupunan ng eksaminer/clinician):
Medical Diagnosis/Diagnoses:______________________________________________
Chronological Age:________________ Hearing Age: __________________

Name of Person Completing the form (Pangalan ng sumasagot sa form): _______________________________

Relationship to the child: _____________ Date Today (Petsa ngayon): ______________
(Relasyon/Kaugnayan sa bata) Age (Taon/Gulang): ____________________
Address (Tirahan): ___________________________________________________________________________________________
Same address with the child? (Parehong address ng sa bata?) ▢ Yes ▢ No
● If no, please state current address of the child (Kung hindi, pakilagay kung saan nakatira ang bata):
_________________________________________________________________________________________________________
Contact Number: ___________________________ Email Address: _______________________________
Other Contact Information (e.g., Facebook Messenger) ____________________________________

II. Primary Concern/s:

Please describe your main concern/s regarding the child's reported problem/s (Pakilarawan ang
problema/concern na ito sa kung paano ito napapansin sa bata):

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
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III. Medical History

1. Is the child diagnosed with any medical condition/s (Nasuri o na-diagnose ba ang bata ng
anumang kondisyong medikal)? ▢ Yes ▢ No
If yes, please specify or describe (Kung oo, ano ito o pakilarawan):

2. Were there any past hospitalizations? (Na-ospital na dati)? ▢ Yes ▢ No

If yes, please specify when and describe (Kung oo, kelan ito at pakilarawan):

3. Is the child taking any medication/s (May iniinum bang gamot ang bata)? ▢ Yes ▢ No
If yes, please specify (Kung oo, ano ito):

4. Does the child have allergies (May mga allergy)? ▢ Yes ▢ No

If yes, please specify or describe (Kung oo, ano ito o pakilarawan):

5. Does the child have any vision problems (May problema sa paningin)? ▢ Yes ▢ No
If yes, please specify or describe (Kung oo, ano ito o pakilarawan):

6. Does the child have any feeding/swallowing problems (May problema sa pag-kain o pag-
lunok)? ▢ Yes ▢ No If yes, please specify or describe (Kung oo, ano ito o pakilarawan):

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
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 7. Does the child have regular medical checkups (Nagkakaroon ng regular na medikal checkup)?
▢ Yes ▢ No
If yes, please specify date of recent visit to the doctor (Kung oo, kelan ang huling checkup?):

IV. Birth and Developmental History

Pregnancy Duration (Haba ng pagbubuntis): __________________
1. Were there any problems/concerns during (Nagkaroon ng problema noong):
a. Pregnancy (Pagbubuntis)? ▢ Yes ▢ No
If yes, please describe (Kung oo, pakilarawan):



b. Labor (Pangangak)? ▢ Yes ▢ No
If yes, please describe (Kung oo, pakilarawan):



c. Upon birth (Sa pagsilang)? ▢ Yes ▢ No
If yes, please describe (Kung oo, pakilarawan):



2. Were there any problems/concerns during (Nagkaroon ng problema noong):
a. The first 6-12 months of the child (Sa unang anim hanggang labingdalawang buwan ng
bata)? ▢ Yes ▢ No If yes, please describe (Kung oo, pakilarawan):

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
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 3. At what age were you able to observe the child to initially (Sa anong edad mo unang nakita ang
bata na):
a. Crawled (gumapang):
b. Sat independently (umupo mag-isa):
c. Walk (maglakad):
d. Respond to sounds (mag respond sa mga tunog):
e. Respond to your voice (mag respond sa iyong boses):
f. Turns and looks in the direction of the sounds (Sundan at tingnan ang direksyon ng mga
tunog):
g. Make sounds (Gumawa ng sounds):
h. Imitate sounds (Gayahin ang mga tunog):
i. Talk (magsalita)
• Babble (“bababa”, “papapa”):
• Talk using one to two words (magsalita gamit ang isa o dalawang salita):
• Talk using sentences (magsalita gamit ang mga pangungusap):
j. Answers simple questions (e.g., “Who?”, “What?”, “Where?”, and “Why”) (Sumagot sa mga
tanong):
k. Follows instructions and commands (Sumunod sa mga instruksiyon o utos):
l. Feed oneself (kumain mag-isa):

4. Please describe any other notable observations in the child's development (Pakilarawan ang
anumang kapansin-pansing obserbasyon habang lumalaki ang bata):

V. Speech and Language History

1. Any family history of speech and language disorders/problems? (Sa inyong pamilya, mayroon
bang kasaysayan ng pagkakaroon ng problema sa pagsasalita o pakikipag komunikasyon)?
▢ Yes ▢ No If yes, please specify and describe (Kung oo, ano ito at pakilarawan):

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
4
 2. What is/are the languages spoken at home (Ano ang mga wikang ginagamit sa bahay)?


3. What is/are the child’s languages (Ano ang mga wikang ginagamit ng bata)?

4. How does the child communicate/interact at home and with others of his/her home (Paano
nakikipag-usap o nakikipag-ugnayan sa bahay at sa ibang tao (e.g. gamit ang aksyon/gestures,
mga tunog/tumitili/umiiyak, kaunting salita, mga pangungusap)?

5. Do you have any concerns/problems understanding the child's speech?

(May pagkakataon ba na hindi o mahirap intindihin ang sinasabi ng bata?) ▢ Yes ▢ No
If yes, please describe (Kung oo, pakilarawan ito):






a. Do others (those unfamiliar to the child) have a similar concern/problem?
(May pagkakataon ba na hindi o mahirap intindihin ng iba ang sinasabi ng bata?)
▢ Yes ▢ No If yes, please describe (Kung oo, pakilarawan ito):





b. Are there specific sounds/letters/words the child had problem with? (Meron bang mga
espisipikong letra, tunog, o salita kung saan mas nakikita ang kahirapan ng bata?)

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
5
 6. Does the child have any difficulties understanding other people’s speech?
(May problema o kahirapan ba ang bata na intindihin ang sinasabi ng iba o ng kaniyang
kausap)? ▢ Yes ▢ No
If yes, please describe (Kung oo, pakilarawan ito):







VI. Audiological History (If applicable/Kung naangkop sa bata)

1. When was the problem or concern in hearing first noted? Please describe. (Kelan niyo unang
napansin ang problema ng bata sa pandinig? Pakilarawan ito.)





2. Who were the professionals seen by the child regarding the stated concern or problem? (Sino-
sino ang mga propesyonal/eksperto na tumingin sa bata ukol sa napansing
karamdaman/problema?)


3. How often does the child undergo follow-up consultations with his doctor or audiologist?
(Gaano kadalas nakikita ng bata ang kaniyang audiologist o doktor?)


a. What is/are the child's initial hearing diagnosis/diagnoses? (Ano ang hearing diagnosis
ng bata?)



b. From these follow-up consultations, was there a change in the child's initial diagnosis?
(Sa mga nagdaang konsultasyon ng bata, may nag-iba ba sa unang diagnosis sa kanya?)
▢ Yes ▢ No If yes, please indicate (Kung oo, pakilarawan ito)





Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
6
 4. What is/are your suspected cause/causes of the child's hearing loss? (Ano ang inyong
perception/pang-unawa sa naging dahilan kung bakit may kahirapan sa pandinig ang bata?)

5. What audiologic procedures and/or hearing tests were administered to the child? (Anong mga
ginawang procedure at/o eksaminasyon sa pandinig ng bata?)




6. Does the child have any amplification devices? (Mayroon bang amplification device o hearing
aid ang bata)? ▢ Yes ▢ No
If yes, please specify and describe (Kung oo, ano at ilan ito, saang tenga nakalagay, at
pakilarawan ang model, type, brand, setting/volume):

7. When was the amplification device installed? (Kailan unang kinabit ang hearing device ng
bata?)

6. What are your and the child's experience with the installed hearing device? Please describe.
(Ano ang karanasan ninyo at ng bata sa kanyang hearing device? Pakilarawan.)

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
7
 a. How long does the child wear the hearing device in a day? (Gaano katagal sinusuot ng bata ang
kaniyang hearing device sa isang araw?)





VII. Intervention and Educational History

1. Did the child receive or is receiving any speech, occupational, or physical therapy? (Tumanggap o
tumatanggap ba ang bata ng speech, occupational, o physical therapy)? ▢ Yes ▢ No
If yes, please specify and describe the therapist/s, clinic/hospital, etc. (Kung oo, ano ito at pakilarawan
ang therapist, clinic/ospital, o iba pang impormasyon):






i. Duration of intervention/therapy (anong taon at gaano katagal):
___________________________________


ii. What are your perceived results (Ano ang napansin niyong epekto nito)?





If applicable, please state (kung naaangkop, pakilagay):
2. Referral Process (Proseso ng Referral):
a) Was the child assessed by a developmental pediatrician? (Nakita at na-assess ba ng isang
developmental pediatrician ang bata?) ▢ Yes ▢ No Please describe the consultation
(Ilarawan ang nagging konsultasyon):



b) Who was the professional seen by the child? (Sinong propesyonal ang tumingin sa bata?)
____________________________

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
8
 c) When and where was the assessment performed? (Kelan at saan naganap ang assessment?)
________________________________________
d) What was the result of the assessment? (Ano ang resulta ng pag konsulta?)

1. When did the child first entered school or received any formal educational
experience/intervention (Kelan unang pumasok ang bata sa eskuwelahan o nakatanggap ng
kung ano mang karanasang may kinalaman sa edukasyon)? Please specify and describe (kung
oo, ano ito at pakilarawan):



2. If the child is in school, what grade is he/she in (Kung ang bata ay nag-aaral, ano ang kaniyang
grade o level)? ____________
a. School/Paaralan:
b. Type/Uri ng Paaralan:
c. Number of students in the class/Ilan sila sa klase?
3. How is the child in school (Kumusta siya sa paaralan)?
Please state any concerns or notable observations (Pakilarawan):

VIII. Family and Social History

1. Please state the following about the child's family (Pakilagay ang sagot sa mga sumusunod na
impormasyon tungkol sa pamilya ng bata):
a. Father’s name: ______________________________________________________

i. Occupation (Trabaho): _____________________________________

b. Mother’s name: _____________________________________________________

i. Occupation (Trabaho): _____________________________________

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
9
 c. Number of sibling/s (Bilang ng kapatid/mga kapatid):___________

i. Name of Sibling and Age: ________________________________________

ii. Name of Sibling and Age: ________________________________________

iii. Name of Sibling and Age: ________________________________________

iv. Name of Sibling and Age: ________________________________________

2. Who is/are the members of the household (Sino-sino ang kasama ng bata sa bahay)?
Please describe (Pakilarawan):



3. Who is/are the primary conversational partners of the child (Sino-sino ang madalas niyang
nakakausap)? Please describe (Pakilarawan):




4. Please describe the interests/hobbies of the child (Pakilarawan ang interes o mga hilig niyang
gawin) (e.g., Sports, Hobbies, Toys/Laruan, TV shows, Characters):




a. What are the activities that the family enjoys doing (Ano-ano ang mga gawain na
kinagigiliwang gawin ng buong pamilya)?



5. Please describe how the child interacts with others (e.g., friends, neighbors, strangers,
teachers, schoolmates, etc.) (Pakilarawan kung paano nakikipag-ugnayan ang bata sa ibang tao
(e.g., kaibigan, kapitbahay, guro, kaklase, o sa ibang tao):

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
10
 6. Please describe the usual routine of the child (Pakilarawan ang pang araw-araw niyang
gawain):




7. Please describe the child’s behavior (Pakilarawan ang pag-uugali ng bata):




8. Please describe the form of discipline used at home (Pakilarawan ang paraan ng pagdidisiplina
sa bata):

IX. Goals and Expectations

A. Please state your goals in receiving Speech-Language-Hearing Therapy (Pakilagay ang inyong mga
layunin sa pagtanggap ng Speech-Language-Hearing therapy).





X. Other Concerns/Additional Information:





Printed Name and Signature (Pangalan at Pirma): ________________________________________________
Date Completed (Petsa kung kailan sinagutan): _______________________

Adapted from Newton-Wellesley Hospital Rehabilitation Services. Mass General Brigham. (n.d.). Retrieved from
https://www.nwh.org/media/file/NWH_Pedi_Speech_fillable.pdf
LFRR | 2022
11