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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
Select All
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: