Case History Form - Simcoe Speech Clinic

General Information

Name:

First

Last

Date of Birth:

Referred By:

Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Phone (ALT)

Email:

Background -

Provide information and history about any of the following:

Mother's Name:

Occupation:

Father's Name:

Occupation:

Does the client live with both parents?

Other people in the home:

Was hearing tested?

Primary language spoken at home:

Other language(s) spoken at home:

If Child does not live with both parents, please provide any documents for custody concerns. Consent needs to be provided by the adult bringing the child to the assessment/consult to share any information with others. Please provide more information to the SLP at the appointment, if needed.

Medical History - Provide information and history about any of the following:

Allergies
Asthma
Meningitis
Colds
Convulsions
Headaches
Dizziness
Seizures
Mastoiditis
Encephalitis
Draining Ear/tubes
Ear Infections
High Fever
German Measles
Mumps
Measles
Influenza
Sinusitis
Pneumonia
Tonsillitis
Low Immunities
Tinnitus
Chicken Pox
Other

Areas of concern:

Any surgeries, major accidents or hospitalizations?

Diagnosis or learning difficulties?

Who provided the diagnosis and when was the diagnosis? If any report is available please provide.

Is the child on any medication? Please explain:

Any concerns with feeding/eating and swallowing? Please explain:

Picky eater?

Developmental History -

Provide the approximate age at which the child began to complete the following:

Crawl:

Sit:

Walk:

Feed self:

Dress self:

Use toilet:

Babble:

Use single words:

Combine words:

Name simple objects:

Use greetings:

Use simple questions:

Engage in conversation:

Play with peers:

Look through books:

Point to items:

Highlight the best way to describe the child’s response to sound:

Responds to all sounds
Responds to loud sounds only
Inconsistently responds to sounds

Does the child respond to their name?

Has hearing been tested and what were the results?

Prenatal and Birth History -

Provide information on any concerns with the following:

Mothers health during pregnancy:

Any medications?

Length of pregnancy:

Birth weight:

General condition:

Complications:

Type of delivery:

Unusual conditions:

Other:

Speech Concerns - Describe the concerns you have for the child?

How does the child usually communicate?

When was the problem first noticed?

Any family history of speech and language concerns or learning disabilities or reading concerns?

Is the child aware of the concern? If yes, how does he/she feel about it?

Educational History -

Provide information on any of the following:

Name of school:

Grade:

Concerns academically:

Behavior:

Teacher:

Special considerations/support:

How does the child interact with others at school?

Is there a recent IEP? Please attach or provide the goals, weaknesses and strengths:

Provide any additional information that you feel is relevant to support the speech and language assessment: