SPEECH-LANGUAGE PATHOLOGY Child Case History Formshcjax.org/.../07/Child-New-Patient-Paperwork-SPEECH-Case-History-… · SPEECH-LANGUAGE PATHOLOGY Child Case History Form Parent’s

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1128 North Laura Steet Jacksonville, FL 32206 Telephone (904) 355.3403 Fax (904) 355-4149 www.shcjax.org

SPEECH-LANGUAGE PATHOLOGY Child Case History Form

Parent’s confidential report: All of the following information is for the use of the Jacksonville Speech & Hearing Center’s professional staff and will be handled in confidence. A request has been made for an examination of your child. In preparation for this examination, we would like you to provide the information requested on this form. This information will assist the Center staff in completing a meaningful examination. Please answer the questions as fully and accurately as possible. If you are not sure of a particular answer, please place a question mark after it. Thank you. Date __________________ Person Completing Form ____________________________ Relationship to Child _______________________ Child’s Name _____________________________________________________________________________ Last First Middle Date of Birth ____________________________ Sex ______________ Address _________________________________________________________________________________ Street Apt # City ___________________________________ State ___________County____________ Zip____________ Telephone(s) Home _________________________________ Work _______________________________ Cell __________________________________ Pager _______________________________ Child’s Pediatrician (PCP) ___________________________________________________________________ Address _________________________________________________________________________________ Telephone _____________________________________ Fax _____________________________________ Did the patient receive a speech/language screening at his/her daycare?__________________________ How did you hear about us: r Newspaper r Friend r Word of mouth r Relative r Health newsletter r Health fair screening r Web site r Doctor refer r Yellow pages r Post Card r Other__________________ Has the Patient been here before? Y/N When? _________________________________________________ Briefly describe your child’s problem? __________________________________________________________



________________________________________________________________________________________ When was the problem first noticed? ___________________________________________________________ What has been done about it? ________________________________________________________________

FAMILY HISTORY

FATHER’S Name __________________________________________________________ Age __________

(circle one) Natural Adoptive Custodial

Education ______________________________________ Occupation ________________________________

Place of Employment _________________________________________ Work Phone ___________________

Health Status _______ Good _______ Fair _______ Poor Hand Preference _______ Right _______ Left

Presence in Father’s family of :

____ Asthma ____ Hearing Loss ____ Mental Illness ____ Mental Retardation ____ Drugs ____ Epilepsy

____ Learning Disorder ____Speech Deficit ____Blood Diseases (Sickle Cell, Diabetes, STD, other)

MOTHER’S Name _________________________________________________________ Age __________

(circle one) Natural Adoptive Custodial

Education ______________________________________ Occupation ________________________________

Place of Employment _________________________________________ Work Phone ___________________

Health Status _______ Good _______ Fair _______ Poor Hand Preference _______ Right _______ Left

Presence in Mother’s family of :

____ Asthma ____ Hearing Loss ____ Mental Illness ____ Mental Retardation ____ Drugs ____ Epilepsy

____ Learning Disorder ____Speech Deficit ____Blood Diseases (Sickle Cell, Diabetes, STD, other)

Marital Status of Parents: ___ Married ___ Separated ___ Divorced ___ Unmarried Is either parent ever away from home? Y / N When? _________________ Why?___________________

________________________________________________________________________________________

Other family members in household:

Name Relationship Age Education/Occupation

________________________ _________________________ ___________ _____________________

________________________ _________________________ ___________ _____________________



________________________ _________________________ ___________ _____________________

________________________ _________________________ ___________ _____________________

Does any member of the family have a similar problem? Yes No Any family member (present or past) with a hearing problem? Yes No

PRENATAL & BIRTH HISTORY During pregnancy was mother exposed to antibiotics? Yes No During pregnancy was mother exposed to radiation? Yes No Was amniocentesis done during pregnancy? Yes No Were RH factors compatible? Yes No During pregnancy did mother have: (Circle all that apply) Bleeding Anemia Diabetes Toxemia During pregnancy was mother exposed to: (Circle all that apply.)

Measles/Mumps Syphilis Chicken Pox German Measles Herpes Virus Influenza Cytomegalovirus (CMV) Toxoplasmosis Other __________________________________________ How long was pregnancy? _________________ months How was mother’s general health during pregnancy? _________________ Any problems with pregnancy or delivery? Yes No Emergency C-section? Yes No Was there premature membrane rupture? Yes No Were forceps/assisted delivery used? Yes No What was: Birth weight? ____________________ Apgar Score? ____________________ Did the infant have any of the following? (Circle all that apply) Breathing problems Oxygen given NICU stay Jaundice Rubella Antibiotics Heart problem Defect of Ear/Nose/Throat/Mouth Paralysis Seizures Exposure to Radiation



Any problems with feeding? (Sucking/Swallowing?) Yes No Use of Feeding (NG) tube Yes No Any other problems/birth defects? Yes No If yes, please describe briefly: ______________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

HEALTH & DEVELOPMENTAL HISTORY Is the child currently taking any medications? Yes No

Please list: ________________________________________________________________________ Has the child had any major surgeries? Yes No

Please list: ________________________________________________________________________ What was infant’s health during first month? Good __________ Fair __________ Poor __________

Has the child had: Age Started Description/Comments Frequent Colds ____________ ____________________________________________ Ear Infections ____________ ____________________________________________ Asthma ____________ ____________________________________________ Vision Problems ____________ ____________________________________________ Physical Handicap ____________ ____________________________________________ Epilepsy/Seizures ____________ ____________________________________________ Attention Deficit Disorder ___________ ____________________________________________ Traumatic Brain Injury ____________ ____________________________________________ Drug Allergies ____________ ____________________________________________ Has the child had any other serious illness, accident or injury? Yes No

If so, briefly describe where and what happened? __________________________________________ __________________________________________________________________________________



Did the child meet all developmental stages on time? (ex. Sitting, Crawling, Walking, Feeding Self)? Yes No

If not, please describe: _______________________________________________________________ __________________________________________________________________________________ Does the child have/show any of the following behaviors: (Circle all that apply) Demands attention Lacks Confidence Unusual stress at home Under active Short attention span Hyperactive Easily managed at home Impulsive Nervous or sensitive Withdrawn Confused in noisy places Daydreams Easily frustrated Tires easily Talks excessively Poor eater Profits from discipline Aggressive Lacks motivation Easily Distracted Overly sensitive to loud noises Prefers to play alone Difficulty following directions Plays well with playmates Makes inappropriate statements Other: _________________________________________________________________________________ ________________________________________________________________________________________

SPEECH & HEARING HISTORY Has the child had ear infections/ear aches/ear abscesses? Yes No

Do you suspect or ever suspected a hearing loss in the child? Yes No

Has the child ever complained about noise in his/her ears? Yes No

Has the child ever been exposed to loud noises/explosions? Yes No

Does the child presently wear a hearing aid? Yes No

Right _______ Left _______ Type of aid? _____________________ How long? __________

Does the child respond to these sounds? (Circle all that apply)

Loud airplanes Doorbell/telephone Faint sounds Speech when facing speaker

Whispers Toy sounds Car horn Speech when back to speaker

Did the child babble of make cooing sounds as an infant? Yes No

Did the child stop babbling before expected to at any time? Yes No

Does the child try to imitate speech? Yes No

Are words used meaningfully? Yes No

Age when first word was used _______________ About how many words does child say now? ____________

Does the child combine two or more words together (such as “Want drink” or “Mommy car”? Yes No



Please give an example: ____________________________________________________________________

________________________________________________________________________________________

Does the child use sentences? Yes No Average length of sentences (# of words): ______________

Who is able to understand the child? ___________________________________________________________

What has been done at home to correct the problem? _____________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

EDUCATIONAL & SOCIAL INFORMATION

School presently attending ___________________________________________________________________

Teacher ________________________________ Any Additional Services ____________________________

Grade level _____________________________ Any grade repeated? Yes No Which grade? _________

Any grade skipped? Yes No Which grade? _________

What are his/her grades in:

Reading ______________ Arithmetic ______________ Spelling ______________

Language ____________ Geography/Social Studies/History __________________

How does the child feel about school and his/her teachers? _________________________________________

________________________________________________________________________________________

Does the child have serious difficulty in any subject/activity? Yes No If yes, what subject?

________________________________________________________________________________________

Does the child excel in any particular subject/activity? Yes No If yes, what subject?

________________________________________________________________________________________

Has the child ever had an intelligence test? Yes No If yes, what were the results?

________________________________________________________________________________________

________________________________________________________________________________________

Does the child have a discipline problem? Yes No If yes, in what way?



________________________________________________________________________________________

________________________________________________________________________________________

ADDITIONAL COMMENTS/OTHER IMPORTANT INFORMATION

Is there any other information you feel would help us evaluate your child? _____________________________

________________________________________________________________________________________

________________________________________________________________________________________

Are there any questions you would like to ask us? ________________________________________________

________________________________________________________________________________________

Have you thought about or made application for other agencies for your child? Yes No

When? ___________________________ Where? _______________________________________________ The Jacksonville Speech & Hearing Center, Inc. is a private, not-for-profit corporation. Fees constitute the majority of our operating budget. Your cooperation in payment of fees in full at time of service is required, unless other arrangements have been made prior to the date of service. Thank you for your time and attention in completing this history form!

Signature of Person Completing this form: _______________________________________________________

Relationship to Child: _______________________________________________________________________

Documents

SPEECH-LANGUAGE PATHOLOGY Child Case History Formshcjax.org/.../07/Child-New-Patient-Paperwork-SPEECH-Case-History-… · SPEECH-LANGUAGE PATHOLOGY Child Case History Form Parent’s