LONGWOOD UNIVERSITY
Speech, Hearing, & Learning Services
315 West Third Street
Farmville, Virginia 23909
Phone (434) 395-2972 – Fax (434) 395-2622
Child Case History – Audiology and Speech-Language Pathology
Date:_____________________
Child's Name:____________________________________________ Date of Birth:__________ Age:__________
Reason(s) for referral?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Hearing History:
How do you think your child hears?_______________________________________________________________
____________________________________________________________________________________________
Yes No
Has your child had a hearing test before? Results? Where?_________________________________
_______________________________________________________________________________
Yes No
Does your child respond when called?_________________________________________________
Yes No
Can your child follow directions?_____________________________________________________
Yes No
Does your child respond to sounds around him/her?_______________________________________
Yes No
Does your child startle to loud sounds?_________________________________________________
Yes No
Is there a family history of hearing loss?________________________________________________
Yes No
Does your child wear hearing aids?____________________________________________________
Yes No
Does your child play with objects and other people in ways that are expected?__________________
________________________________________________________________________________
Speech and Language History:
Age when child babbled (e.g., dadadada)_____
Said first word_____
Put two words together_____
Your child right now is (check those that apply):
_____ Cooing
_____Uses approximately _____ words
_____Babbling (examples:____________________)
_____Putting about _____ words together
_____Communicates by pointing
_____Speaking in sentences
_____Uses gestures
_____Speech is clear
_____Speech is unclear
Yes No
Do you understand most of what your child says?________________________________________
Yes No
Do strangers understand most of what your child says?____________________________________
Yes No
Has your child received speech-language therapy? Where?_________________________________
________________________________________________________________________________
Yes No
Have other family members had speech/language problems or speech/language therapy?_________
________________________________________________________________________________
Yes No
Is English the only language spoken in the home?________________________________________
________________________________________________________________________________
Feeding/Swallowing:
Yes No
Does your child demonstrate eating habits appropriate for his/her age?________________________
If not, please explain _______________________________________________________________
________________________________________________________________________________
Yes No
Does your child have any history of reflux?_____________________________________________
Child Case History
Page 1 of 2
Rev. 11/2014
Pregnancy and Birth History:
Yes No
Was the pregnancy with this child full-term? ____________________________________________
Yes No
Were there any complications during the pregnancy?______________________________________
________________________________________________________________________________
Yes No
During the delivery?_______________________________________________________________
Medical History:
Yes No
Has your child had ear infections?_____________________________________________________
When was the last one?_____________________________________________________________
Yes No
Has your child ever had ear tubes? ____________________________________________________
Yes No
Does your child have seasonal allergies/sinus problems____________________________________
Yes No
Does your child have allergies to foods, medicines, or environmental agents?__________________
________________________________________________________________________________
What reaction does your child have to the allergen(s)_________________________________________________
What action should be taken in case of contact with allergen(s)?_________________________________________
Yes No
Has your child had a serious illness/hospitalizations/surgeries/accidents?______________________
________________________________________________________________________________
________________________________________________________________________________
Yes No
Is your child’s general health good?___________________________________________________
Yes No
Is your child taking any medications?__________________________________________________
Yes No
Has your child’s physical development been normal?_____________________________________
Age when child: Sat alone___________
Crawled____________
Walked______________
Yes No
Are your child’s fine motor skills normal? (for example, buttoning, tying shoelaces, writing)______
________________________________________________________________________________
Right Left Which hand does your child prefer?___________________________________________________
Name of child’s primary care physician:_________________________________ Phone:____________________
Educational History:
Your child currently attends ____________ grade, at ___________________________________________school.
Yes No
Is your child doing well in school (or day care)?_________________________________________
________________________________________________________________________________
________________________________________________________________________________
Yes No
Is your child reading at grade-level?___________________________________________________
Yes No
Does your child enjoy school?________________________________________________________
Yes No
Is your child receiving special help at school?___________________________________________
________________________________________________________________________________
Family Information:
Parent Name:______________________________________________________________ Age:______________
Parent Name:______________________________________________________________ Age:______________
Sibling Names(s) and Age (s): ___________________________________________________________________
____________________________________________________________________________________________
Pet name(s):__________________________________
Hobbies:_____________________________________
Is there any other information that might help us better understand your child or work more effectively with
him/her during the evaluation? ___________________________________________________________________
____________________________________________________________________________________________
Comments:___________________________________________________________________________________
____________________________________________________________________________________________
Name of person completing this form:____________________________ Relationship to the child:____________
EMERGENCY CONTACT INFORMATION:
Name:________________________________________________ Relationship:___________________________
Phone:________________________________________________
Child Case History
Page 2 of 2
Rev. 11/2014