Case History Form.pdf

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Speech-Language-Hearing Case History Form

Identifying Information:

Child’s Name: ______________________________ Date of Birth: ___________________

Parent’s Name (s): ___________________________Home Phone: __________________

Home Address: ______________________________Cell Phone: ____________________

______________________________ Work Phone: __________________

Parent’s Occupation(s): _____________________/ _____________________________

Email Address: ____________________________/ ______________________________

Child’s School: _______________________ Grade: ____ Teacher: _________________

Referred By: _____________________________________________________________

Doctor’s Name: ______________________________ Doctor’s Phone: ______________

Child lives with (check one):

___ Birth Parent ___ Foster Parents ___ Adoptive Parents

___ One Parent ___ Parent & Step-parent ___ Other: ______________

Family History:

Siblings: ____________________________ Age: _______

____________________________ _______

Is there a family history of: Yes/No

Speech/Language Difficulties _____

Hearing Impairment/Deafness _____

Learning Difficulties _____

Developmental Difficulties _____

If you responded “yes” to any of the above, please describe:

Other Language Exposure:

Is there a language other than English spoken in the home? _____ Yes _____ No

If yes, which language? ________________________________

Does the child speak this language? _____ Yes _____ No

Does the child understand this language? _____ Yes _____No

Which language does the child prefer to speak at home? _________ school? _________

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