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New Student Case History Form

SPEECH AND LANGUAGE CASE HISTORY FORM

Child’s Name:(Required)

Date of Birth:(Required)

Age:(Required)

Home Address:(Required)

City:(Required)

State:(Required)

Zip:(Required)

Home Phone:(Required)

Mother’s Name:

Mother's Age:

Mother's Email:

Mother's Occupation:

Mother's Education:

Mother's Phone:

Father's Name:

Father's Age:

Father's Email:

Father's Occupation:

Father's Education:

Father's Phone

Is English the primary language spoken in the home?

If no, what language?

Does your child live with both parents?

If no, please indicate with whom the child lives:

List any other children living in the home:

Name, Sex, Age, School/Grade

Who referred you for this evaluation?

How did you find out about Magnolia Speech School?

What is the purpose of this evaluation?

Check which is applicable: This is our

biological child

foster child

adopted child

Mother’s age at birth:

Number of pregnancies:

When did the mother begin prenatal care?

Where did the mother receive prenatal care?

Physician’s name:

List any illnesses during pregnancy:

List any medications taken during pregnancy:

Did the mother do any of the following activities while pregnant?

drink alcohol

smoke cigarettes

use recreational drugs

Type of delivery:

vaginal

caesarean section

What week of gestation was the baby delivered?

Child’s birth weight:

____ pounds, ____ ounces

Child’s length at birth:

Inches

Baby’s color at birth:

normal

blue

yellow

Did the infant require a stay in the neonatal intensive care unit (NICU)?

If yes, please explain.

Any injuries or deformities at birth?

If yes, please explain.

Did your child pass his/her newborn hearing screening?

If no, please list further testing.

Describe your child’s health during the first weeks of life:

Please check any complications experienced during pregnancy:

high blood pressure

weight loss

excessive weight gain

frequent sonograms

fever

excessive bleeding

toxemia

kidney problems

infections

excessive vomiting

Does your child exhibit any gross motor problems?

walking, hopping, running, other

Does your child exhibit any fine motor problems?

stacking blocks, buttoning, cutting, zipping, other

Please indicate the age in months your child sat alone.

Please indicate the age in months your child walked alone.

Please indicate the age in months your child toilet trained bladder.

Please indicate the age in months your child crawled.

Please indicate the age in months your child drank from a cup.

Please indicate the age in months your child toilet trained bowel.

Please indicate the age in months your child stood alone.

Please indicate the age in months your child used spoon.

What does your child enjoy playing with or doing in his/her free time?

Please indicate the age in months when your child babbled (i.e., bububu, mamama, dadada)

Please indicate the age in months when your child used single words (i.e., mama, no, doggie)

Please indicate the age in months when your child combined words (i.e., me go, daddy shoe)

Please indicate if your child has a family history of the following problems:

hearing

speech

learning

language

reading

Did speech learning ever seem to stop or regress for any period of time? If yes, please explain:

Does your child seem to understand what is said to him/her? If so, how does he/she indicate this to you?

My child is:

Verbal

Nonverbal

Does your child prefer to use?

speech

gesture

both

How does your child communicate needs?

speech

gesture

both

If your child is verbal, he/she speaks using:

single words

2-3 word phrases

single words approximations (i.e., cu for cup)

sentences

How often do others understand your child’s speech?

never

sometimes

most of the time

always

How often do family members understand your child’s speech?

never

sometimes

most of the time

always

 How often does your child use speech?

never

sometimes

most of the time

always

Does your child make any sounds incorrectly? If yes, please explain

How would you describe your child’s speech/language problem(s)?

When was this first noticed? By whom?

What is your child’s attitude towards this problem (e.g. frustrated, angry, indifferent, etc.)?

Name of your child’s physician:

Please indicate if your child has been given a formal diagnosis such as: autism, cerebral palsy, developmental delay, genetic syndrome, etc.:

When was it made?

By whom?

Are your child’s immunizations up to date?

yes

no

Is your child taking any medication?

yes

no

If so, what medications? For what reason?

**IF YOUR CHILD TAKES PRESCRIPTION MEDICATION FOR ADD OR ADHD, PLEASE HAVE HIM/HER TAKE THE MEDICATION AS PRESCRIBED ON THE DAY OF THE EVALUATION.**

Has your child ever had surgery or been hospitalized?

yes

no

If yes, please indicate why, when did this occur?

Please check any of the following your child has had:

hay fever

pneumonia

hepatitis

mononucleosis

asthma

bronchitis

very high fever

sinus infection

tonsillitis

meningitis

seizures

mumps

skull fracture

hyperbilirubinemia

encephalitis

chicken pox

diphtheria

frequent colds

measles

head injury/accident

seasonal allergies

Please list anything your child is allergic to, including any food and/or environmental allergies.

Does your child have an Epi Pen?

yes

no

Does your child’s vision seem normal?

yes

no

Is your child color blind?

yes

no

Has your child had a visual exam?

yes

no

If so, results:

Does your child wear eyeglasses?

yes

no

Does your child have tubes?

yes

no

If yes, which ear(s)?

left

right

Still in Place?

yes

no

When was the procedure done? By Whom?

Does your child have a history of middle ear infection?

yes

no

When was the most recent ear infection?

Please check all that apply:

four or more ear infections in one year

ear infection before the age of one

draining ear

ear problem in the last six months

ear problem lasting three months or longer

Do you think your child has a hearing loss?

yes

no

Has your child ever had a hearing evaluation?

yes

no

If so, when? Where? Results?

Does your child wear hearing aids?

yes

no

If yes, which ear(s)?

left

right

both

Does your child have a cochlear implant?

yes

no

If yes, when was he/she implanted? Where? By whom?

Can your child tell you his/her name?

yes

no

Can your child tell you his/her age?

yes

no

Compared to other children of your child’s age, does he/she look at books independently:

yes

no

Compared to other children of your child’s age, does he/she count to three:

yes

no

Compared to other children of your child’s age, does he/she count to ten:

yes

no

Compared to other children of your child’s age, does he/she point to colors named:

yes

no

Compared to other children of your child’s age, does he/she follow simple directions:

yes

no

Compared to other children of your child’s age, does he/she get along with siblings:

yes

no

Compared to other children of your child’s age, does he/she get along with other children:

yes

no

Compared to other children of your child’s age, does he/she make friends easily:

yes

no

Compared to other children of your child’s age, does he/she play with age appropriate toys:

yes

no

Compared to other children of your child’s age, does he/she enjoy being read to:

yes

no

Compared to other children of your child’s age, does he/she enjoy playing alone:

yes

no

Compared to other children of your child’s age, does he/she enjoy playing with other children:

yes

no

Compared to other children of your child’s age, does he/she easily adapt to change:

yes

no

Compared to other children of your child’s age, does he/she appear overactive:

yes

no

Compared to other children of your child’s age, does he/she appear overanxious:

yes

no

Does your child have difficulty with chewing/swallowing?

yes

no

If so, please indicate the food consistency that causes problems: crunchy, chewy, soft, other:

Does he/she avoid any foods or consistencies?

yes

no

If so, please list:

Does he/she mouth objects (pencils, hands, etc.)?

yes

no

If so, please list:

Does he/she gag easily with food or utensils in mouth?

yes

no

Is your child followed by First Steps?

yes

no

If yes, who is your First Steps Service Coordinator?

Has there been a previous evaluation?

yes

no

When? Where? Result? Recommendations?

Is your child currently receiving treatment for this problem?

yes

no

If yes, where?

Please describe any speech/language, hearing, OT, PT, psychological/behavioral, special education services, or tutoring that your child is receiving/has received.

Has your child been seen by any other professionals for any reason other than routine care?

yes

no

Name of School:

Grade:

Teacher’s Name:

Does your child have any problems with peers, teachers, or learning activities? If so, please explain:

Has your child been evaluated by your public school?

yes

no

If so, what were the results?

Does your child have an eligibility ruling?

yes

no

If so, what is the ruling?

Does your child attend a special education class?

yes

no

If so, what type of class?

If your child did not attend daycare of nursery school, who took care of him/her during the day?

Has your child ever had special tutoring or any type of therapy?

yes

no

If so, when? Where? Whom?

Has your child ever repeated a grade?

If yes, what grade(s)? What were the reasons why your child repeated the grade(s)?

Please describe any behavioral problems your child has:

Information provided by:

Date:

Relation to the child:

Magnolia Speech School | 414 Bozeman Road, Madison, MS 39110 | 601-914-9200

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