Longwood Center for Communication, Literacy & Learning
P.O. Box 513 Farmville VA 23901
Phone: 434.395.2972
Fax: 434.395.2622
CASE HISTORY
CHILD (Educational Evaluation/Tutoring Program)
Note: All information provided on this form will be held in the strictest confidence and
will be released to another party ONLY with your knowledge and consent.
Today’s date:
Person completing questionnaire:____________________
I. IDENTIFYING INFORMATION
Child’s Full Name:____________________________ Date of Birth: ______________________________
Child’s Preferred Name: _______________________ Age: _______ Gender: _____ Grade: ___________
Number of Children in the Home: ______________
Parent’s (Guardian) Name: _______________________________________________________________
Address: ______________________________________________________________________________
Telephone: Home: (____) ________________Work: (____)________________Other(___)_____________
Parent’s Email: _________________________________________________________________________
Referred by: ___________________________________________________________________________
Primary Care Physician: ______________________________Phone:______________________________
Insurance Provider: ______________________________ Provider No. ____________________________
Policy (Member) No. _______________________________________ HMO? Yes ______
No ______
Is Prior Approval Required? ______________________________________________________________
Emergency Contact (other than parent): _____________________________________________________
Relationship to child: ____________________________________________________________________
Address: ______________________________________________________________________________
Phone: _______________________________________________________________________________
Referred by: ___________________________________________________________________________
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II. BACKGROUND INFORMATION
Describe difficulty for which you are seeking assistance for your child.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
When did you first notice this difficulty?
____________________________________________
______________________________________________________________________
______________________________________________________________________
Does anyone in the household speak a language other than English?__________________________
Which language?
___________________________________________________________
III. BIRTH HISTORY
During this pregnancy and delivery, did mother experience any unusual illness, condition, or accident? If
Yes, please describe.
_________________________________________________________
________________________________________________________________________
Length of pregnancy:
___________________ Length of labor: _________________________
Birth was: Normal _________ Caesarean ________ Breech _________ Multiple birth_______________
Please describe any unusual events or problems that occurred during your child’s birth or first year of life.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
IV. MEDICAL and HEALTH HISTORY
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Present physical condition:
_____________________________________________________
Height: _____________ Weight:
____________ Status of Vision: ______________________
Is child currently under a doctor’s care?
_________________ If yes, please explain. ___________
________________________________________________________________________
_______ What were the results? ___________________
________________________________________________________________________
Has your child had a recent physical exam?
Has you child ever been hospitalized?
_______ If “yes”, for what condition(s)? ________________
What, if any, medications is your child presently taking, and for what condition(s)?
________________
________________________________________________________________________
Check any medical/learning condition(s) that the child has experienced.
_____ Allergies
_____ Attention Deficit/Hyperactivity Disorder
_____ Ear Infections
_____ Learning Disability
_____ Seizures
_____ Head Injury
_____ Hearing loss
______ Other (Please Explain) ________________________
______ Vision Problems
V. FAMILY HISTORY
Father’s Name: _____________________________________ Phone: ___________________________
Education: _________________________________________ Occupation: _______________________
Employer:____________________________________________________________________________
Mother’s Name: _____________________________________ Phone: ___________________________
Education: _________________________________________ Occupation: _______________________
Employer: ___________________________________________________________________________
Brothers and Sisters:
Name:
_______________________________________________ Age: _____________
Name:
_______________________________________________ Age: _____________
Name:
_______________________________________________ Age: _____________
Others living in the home:
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______________________________________________________________________
V.
EDUCATION AND INTERESTS
If your child attends preschool, please answer these questions.
When did your child begin a preschool program? ______________________________________________
Name of program:
___________________________________________________________
How often does he/she attend? _____________________________________________________________
Has the teacher expressed concern to you about your child’s speech, language, hearing, motor skills, or
learning? Yes No
If yes, what were the concerns? ____________________________________________________________
How does your child get along with the other children at preschool?________________________________
Any additional information you would like to share about preschool?_______________________________
______________________________________________________________________________________
Does your child have any specific interests? ______________________ If so, please explain. __________
______________________________________________________________________________________
______________________________________________________________________________________
Are you concerned about any behavioral problems? Yes No.
If yes, please explain.________________
______________________________________________________________________________________
______________________________________________________________________________________
If your child attends K-12 school, answer the following questions.
School now attending: ___________________________________________ Grade: _________________
School’s Address: ______________________________________________ Teacher: ________________
What school subjects does your child have difficulty with? ______________________________________
What are his/her grades in these subjects? ____________________________________________________
What subjects are stronger? ________________________________ Grades? _______________________
Has your child’s teacher(s) expressed concerns about your child’s speech, language, vision, hearing,
behavior, or learning? Yes No
If yes, what were the concerns?_____________________________________________________________
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______________________________________________________________________________________
How does your child get along with others at school? ___________________________________________
______________________________________________________________________________________
Does your child have a current IEP (Individualized Education Plan/Program)? _______________________
If so, what teachers or assistants provide your child’s special instruction? ___________________________
______________________________________________________________________________________
Any additional concerns regarding your child’s school performance? ______________________________
______________________________________________________________________________________
Are you concerned about any behavioral problems? Yes No If yes, please describe.
______________________________________________________________________________________
______________________________________________________________________________________
Does your child have any particular interests or hobbies? ______ If so, please describe. _______________
______________________________________________________________________________________
VI.
OTHER EVALUATIONS:
Have you seen other professionals regarding your child’s difficulty? Yes __________ No _____________
If yes, please provide the names of other persons who have been consulted. Provide your impressions of
the outcomes of the professional’s service. Include physicians, speech-language pathologists, audiologists,
psychologists, and teachers you have consulted.
Name: __________________________________ Address: _____________________________________
Profession: _________________________ Date(s) of consultation: _______________________________
Outcome(s): ___________________________________________________________________________
______________________________________________________________________________________
Name: __________________________________ Address: _____________________________________
Profession: _________________________ Date(s) of consultation: _______________________________
Outcome(s): ___________________________________________________________________________
______________________________________________________________________________________
Name: __________________________________ Address: _____________________________________
Profession: _________________________ Date(s) of consultation: _______________________________
Outcome(s): ___________________________________________________________________________
______________________________________________________________________________________
Thank you for taking the time to provide us with this information. We will need your permission in order to
request reports from other professionals who may help us to understand your difficulty.
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