Today’s Date:
____________________
Nature’s Communication Center
Where speech and language are natural…
CASE HISTORY FORM
Please be as detailed as possible when filling out this form. The information obtained is very useful in
gaining a clear understanding of you or your family member’s history thus far. We appreciate your time
and thoughtfulness in completing this form.
PERSONS FILLING OUT THE CASE HISTORY FORM:____________________________________________
_____________________________________________________________________________________
RELATION TO PATIENT: _________________________________________________________________
BIRTH HISTORY
PREGNANCY: Any complications? Yes No
If yes, check the items that apply:
Illness
Injury
Fainting spells Bleeding
Anemia Toxemia Placenta previa
Operations
Did the mother use any of the following during pregnancy (If so, check those that apply):
Alcohol
Tobacco
Medications
Recreational Drugs
Describe your pregnancy:
DELIVERY:
# of weeks gestation:
Birth weight:
lbs.
oz.
APGAR scores:
Any complications with labor/delivery? Yes
No
Was there any: Fetal distress
Delivery aided by forceps or suction
Cesarean section
Multiple births
Jaundice
Congenital defects
Feeding difficulty
Respiratory problems
Limpness
Other :___________________________________________________
Comments:
MEDICAL HISTORY
HEALTH COMPLIC ATIONS?
Yes No
Has the patient had any of the following?
If yes, check the items that apply:
Reflux
Allergies
Asthma
Seizures
Heart problems Lung problems Ventilation tubes
Ear Infections
Operations
Chronic or other recurrent medical conditions
Strokes
Falls
Neurological problems
Tremors
Voice problems
Dehydration issues
Has the patient been hospitalized?
Yes No
Date:___________________________________
Please describe:_____________________________________________________________________
_____________________________________________________________________________________
P.O. Box 518 Bellevue, WA 98009
Phone: 425-458-5885 FAX: 425-458-5886
Nature’s Communication Center
Where speech and language are natural…
Has the patient had any physical injuries?
Yes
No
Date:___________________________________
Please describe:_____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has the patient had any major illnesses?
Yes
No
Has the patient’s vision been tested?
Yes
Date:___________________________________
No
Has the patient’s hearing been tested?
Yes
Date:___________________________________
No
Has the patient been diagnosed with any other diseases, disorders, or syndromes? Yes
No
Date:___________________________________ By: __________________________________________
Diagnosis:
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list current medications the patient is taking? _________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is the patient aware of their medical conditions and/or limitations? Yes
No
Has the patient used non-traditional medical approaches in the past? Yes
No
If yes, please describe detail and location of where services were obtained. _____________________
_____________________________________________________________________________________
Other Important Information:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
P.O. Box 518 Bellevue, WA 98009
Phone: 425-458-5885 FAX: 425-458-5886
Nature’s Communication Center
Where speech and language are natural…
DEVELOPMENTAL HISTORY
Were Developmental Milestones met? Yes No
If No, please give detail:
_____________________________________________________________________________________
Please describe the patient as an infant:
Very irregular sleep patterns
Cried a lot/fussy/ irritable
Very difficult to console
Diagnosed with Colic
Difficulties with sucking
Seeking movement at all times
Content to be in one place
Craved being held
Avoided eye contact
Difficulties with feeding
Breast fed/ bottle feed
Avoided exploring with hands
Did not respond to
Did not smile with adults
Had difficulty with bottle
environmental sounds
during talking/interactions
transitions to cup
Please describe the patient as a toddler:
Temper tantrums
Meltdowns
Self inflicting behaviors
Odd speech/mannerisms
Uncontrollable behaviors
No concerns
Please describe the patient as a child/teen:
Overly quiet, withdrawn
Too impulsive
Unresponsive to pain
Trouble focusing attention
Difficulty following directions
Difficulty seperating / parent
Overly sensitive to visual stim
Overly sensitive to odors
Overly senstive to motion
Overly sensitve to touch
Decreased peer engagement
Restless/can’t sit still
Resistant to change in routines
Trouble falling/staying asleep
Strong emotional responses
Has difficulty communicating
Is a perfectionist
Has anxiety over most tasks
Safety is a concern
Runs when door is opened
Overly strong response to pain
Tires/fatigues easily
Chews on nonfood items
Memory difficulties
Behavior problems/difficulties
Perfers toys over people
Time management issues
Frustrated with peers
Avoids talking situations
Overly friendly/boundry issues
Has unusual fears
Immature play skills
Difficulty learning new tasks
Overly sensitive to sounds
Clumsy compared to peers
Frequently rocks/spins self
Sleeps with parent
Unusually anxious
Destructive with toys
Is frustrated easily
Frequent temper tantrums
Abilitiy to entertain onself
Has difficulty with organization
Frustrated with talking
Excessivly worries
Additional Comments:
When did you first have concerns regarding the patient?
FAMILY INFORMATION
MEMBERS OF HOUSEHOLD
AGE
P.O. Box 518 Bellevue, WA 98009
RELATIONSHIP
RELEVANT MEDICAL INFO
Phone: 425-458-5885 FAX: 425-458-5886
Nature’s Communication Center
Where speech and language are natural…
COMMUNICATION PARTNER INFORMATION
NAME
RELATIONSHIP
PHONE
EMAIL
RELATIONSHIP INFORMATION
What kinds of things do you do together?
List any organized tem sports/clubs patient participates in:
How do you respond when you’re frustrated?
Describe a behavior that is a problem to manage:
What do you want from this evaluation/intervention?
I wish the patient/I could:
Comments: Is there any other information that would be beneficial to know regarding the patient, their
family, or past history?
WORK/SCHOOL PERFORMANCE INFORMATION
The patient currently attends/works at: ___________________________________________________
________________________________________Full/Part-time:___________Grade:________________
Supervisor/Teacher’s Name: _____________________________________________________________
Strengths:
P.O. Box 518 Bellevue, WA 98009
Phone: 425-458-5885 FAX: 425-458-5886
Nature’s Communication Center
Where speech and language are natural…
Weakness:
Behaviors/Problems:
Is the patient successfully meeting all expectations?
Do you believe the patient needs additional resources or help in this environment?
PERFORMANCE: (Check those that apply):
Dislikes school/work
Props head for table activities
Finds PE/sports frustrating
Reversal of letters/numbers
Difficulty organizing material
Does not tolerate riding thebus
Gets mixed up with right vs left
Has learning problems
Has more than one peer/friend
Independently engages with all
Is aware of inappropriate
Is not aware of inappropriate
behaviors/interactions
behaviors/ interactions
Often brings work home to
Has difficulty multi-tasking
finish
Gets confused on tasks
Has poor handwritting
Difficulty attending to tasks
Unable to cut with scissors
Social problems
Time management consistenly
effects work production
Often needs support to
complete typical tasks everyday
Comments:
Favorite Free/Past-time activities:
Enjoyable activity/tasks at work/school:
Social Skills/interactions:
Concerns:
P.O. Box 518 Bellevue, WA 98009
Phone: 425-458-5885 FAX: 425-458-5886