Case History by n9P0aK

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									                                Case History

Client’s Name: ________________________ Today’s Date:_________

Date of Birth: ______________                       Age: ________

Parent/Guardian Name: ______________________________
Address:____________________________
        ____________________________
Home Phone #: __________________ Work/Cell #: ______________
Referred by: ____________________________________________

Language(s) spoken at home: ________________________________

Medical History
Were there any unusual conditions that may have affected the pregnancy or
birth?


Describe any major accidents or hospitalizations.


Is your child taking any medications?


Does your child have any known allergies?



Developmental History
When did your child use single words: ________________________
Combine words (e.g. bye bye daddy, mommy shoe) ____________________
Use simple questions/phrases (e.g. what’s that, doggy go night night) ________
Does your child have difficulty walking, running, or participating in other
activities which require small or large muscle coordination?




Are there or have there ever been any feeding problems (e.g. problems with
sucking, swallowing, drooling, chewing)?




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Describe your child’s speech-language problem.




How does your child usually communicate (gestures, single words, short phrases,
sentences)?




When was the problem first noticed? By whom?




What do you think may have caused the problem?




Do you have additional concerns about your child’s development?




School History
Where does your child attend school/daycare? _______________________
Grade: ________________________ Teacher: ___________________
Speech Language Pathologist: __________________________________
Does your child receive any special services at school?




Please provide any additional information that might be helpful in the evaluation
or remediation of the child’s problem.




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