Speech-Language-Hearing
Case History Form
Name:​ ________________________________________
DOB:​ _________________________________________
Date of Eval:​ ___________________________________
Age: ​__________________________________________
Background Information:
Reason for Evaluation: ​(intelligibility, overall communication, etc)
Previous Services: ​(related service & frequency & location)
Birth History:
Medical History: ​(hospitalizations, ear infections, sicknesses)
Family History: ​(siblings and/or parents had services)
Language:
Hearing: *​**Has child had an audiological? Yes / no
Behavioral Observation:
Attention: ​(Did child notice examiner in room? Will the child respond to sound while playing?, Respond to
name?)
Eye Contact: ​(Consistent? During preferred activity? When wanting something?)
Play:​ (Interactive? Symbolic? Pretend?)
Expressive Language:
Utterance length and examples:
Description of language: ​(Percentage understood by familiar & unfamiliar listeners) (Gestures? Pointing?)
Receptive Language:
Answer Questions:
Follow Directions:
Concepts (qualitative, quantitative, spatial, descriptor, etc):
Articulation:
Sound errors, distortions, substitutions, etc:
Percentage understood by: familiar listeners _______%
unfamiliar listeners _______%
Vowels:
Phonological Processes:
Feeding/Oral Motor:
Bottle/pacifier/cup/diet: ​(Overstuffs? Choking/gagging? Different Textures?)
Oral Peripheral: ​(speech and non speech movements) (open mouth posture? Mouth breather?) (Non-food
items in mouth?)
Voice/Fluency:
low/high volume, high pitch, monotone, rapid speech, etc.
Other Pertinent Information:
Recommendations: