Speech Assessment Case History Form "*" indicates required fields Step 1 of 8 12% Child's Name* First Last Date of Birth* MM slash DD slash YYYY Child's race/ethnicity* Gender* Parent/Guardian #1* Parent/Guardian #1 occupation(s)* Parent/Guardian #2 Parent/Guardian #2 occupation(s) Preferred phone*Other phoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred email for correspondence (1st)* Preferred email for correspondence (2nd) Referred by* Doctor's name Doctor's phone Family HistoryChild lives with:* Birth parents Adoptive parents One parent Parent & step-parent Foster parent(s) Other Other: Number of SiblingsSelect0123456More than 6Sibling #1 Name Sibling #1 AgeSibling #2 Name Sibling #2 AgeSibling #3 Name Sibling #3 AgeSibling #4 Name Sibling #4 AgeSibling #5 Name Sibling #5 AgeSibling #6 Name Sibling #6 AgePlease list additional sibling names and ages below: Do any close family members have a history of the following:Speech/Language Difficulties Yes No Family Member(s) with Speech/Language Difficulties Learning Disabilities (ex: dyslexia) Yes No Family Member(s) with Learning Disabilities (ex: dyslexia) Hearing Impairment/Deafness Yes No Family Member(s) with Hearing Impairment/Deafness If you responded "YES" to any of the above, please explain:Is any 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? Why is this speech evaluation being requested? Birth HistoryWas the child born premature? Yes No If yes, how many weeks?Was the child healthy at birth? Yes No If no, please explain:Was there anything unusual about the pregnancy or delivery? Yes No If yes, please explain: Medical HistoryPlease check all that apply: Tonsillitis Adenoidectomy Tonsillectomy Difficulty sleeping Snoring Breathing difficulties Frequent colds Seasonal allergies Nasal congestion Chronic ear infections Hearing loss Ear (PE) tubes Vision problems Wears glasses Head Injuries Other medical/genetic diagnoses: Additional medical information (surgeries, hospitalizations, medications, etc.):Date of last hearing screening: MM slash DD slash YYYY Location: Results: Pass Fail Date of last vision screening: MM slash DD slash YYYY Location: Results: Pass Fail Feeding/Eating HistoryCheck all that apply: Thumb/finger sucking Pacifier use Difficulty nursing Reflux/Colic Tongue thrust Messy eater Limited diet Food texture sensitivity Drooling observed Tongue or lip tie present Food allergies Weight issues Picky eater Choking/coughing while eating Sensitive gag reflex If you checked any of the above, please explain:Was your child… bottle fed breastfed How long? Does your child primarily breathe through their… nose mouth unsure Developmental HistoryIndicate the approximate age at which your child reached the following milestones:Sat alone Crawled Walked Toilet trained Grasped crayon/pencil Began to scribble/draw Do you consider any physical/motor milestones to be delayed or impaired? Yes No If yes, please explain:Check all that apply: Unusually active/fidgety Easily overwhelmed Low muscle tone Overly sensitive to sound Clumsy Overly sensitive to touch If you checked any of the above, please explain:Has your child been diagnosed with a developmental disability or behavioral disorder? Yes No If yes, please specify: Educational/Academic HistoryDoes your child attend school? Yes No Child's school/district: Teacher: Grade: Does your child have an active 504 plan? Yes No If yes, what service(s) does he/she receive? Does your child have an active IFSP or IEP? Yes No If yes, under what eligibility/diagnosis? Does your child receive any other therapies? Yes No If yes, please list: Has your child ever received a speech/language evaluation? Yes No If yes, when and by whom? Has your child received speech/language therapy previously? Yes No If yes, when and by whom? Is your child reading? Yes No Did they have or are they having a difficult time learning to read? Yes No Is your chlid having difficulty with a particular subject? Yes No If yes, which subject(s)? Has your child ever repeated a grade? Yes No If so, what grade and why? Is your child receiving any other help at school/home (e.g., tutoring, etc.)? Yes No If yes, please list? Speech & Language DevelopmentIndicate the approximate age at which your child reached the following milestones:Babbled Said first words Put two words together Spoke in short sentences Was your child a quiet infant (limited vocalizations/babbling)? Yes No Unsure Did your child produce any consonant sounds in babbling by 12 months? . . (e.g., "mmm", "dah", etc.) Yes No Unsure Did anything concern you about your child's speech development? Yes No Unsure If yes or unsure, please explain:Does your child prefer to communicate with: gestures words both neither Does your child:Follow simple directions? Yes No Follow complex or multi-step directions? Yes No Ask questions? Yes No Understand what you are saying? Yes No Identify objects and actions easily? Yes No Respond correctly to yes/no questions? Yes No Is your child's speech easily understood by most people? Yes No If you checked "NO" for any of the above, please explain:Is your child aware of or frustrated by any speech difficulties? Yes No If yes, please explain: What are your specific concerns regarding your child's speech?Please provide some examples of a typical sentence or utterance your child says:reCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
