Longwood Center for Communication, Literacy & Learning
P.O. Box 513 Farmville, VA 23901
Phone: 434-395-2972 Fax: 434-395-2622
CASE HISTORY
CHILD SPEECH, VOICE, LANGUAGE
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: _____________________
Completed by: ___________________
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: _______________________________________________________________________
Relationship to client: ___________________________________________________________
Referred by: ______________________________________________________________
II. BACKGROUND INFORMATION
Describe difficulty for which you are seeking assistance for your child.
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When did you first notice this difficulty? ____________________________________________
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What do you think caused this communication difficulty? _______________________________
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Have you noticed any change in the child’s communication difficulty since the
beginning? Please explain. _______________________________________________________
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Does the child have difficulty understanding the speech of other people? Please explain.
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What questions would you like answered as a result of this evaluation?____________________
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Describe the reaction of people, including your immediate family, to the child’s
communication difficulty? _______________________________________________________
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What would you like to change about the child’s communication abilities? _________________
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What difference would the change(s) make in the child’s daily activities at home and/
or at school? __________________________________________________________________
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Describe anything you have done to help your child with the communication difficulty.
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Describe any situations which make it more difficult for your child to communicate. _________
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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 ____________________
Was your child in the neonatal intensive care unit after birth (NICU)? ______________________
How long? _____________________________________________________________________
Please check any conditions that applied to your child immediately after birth:
____difficulty breathing ____sucking problems
____seizures
____blue skin
____swallowing difficulties
____bruises
____jaundice
____feeding problems
____cord wrapped around neck
____genetic disorder
____meningitis
____AIDS (HIV)
Please describe any unusual events or problems that occurred during your child’s birth or first
year of life. ____________________________________________________________________
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IV. MEDICAL and HEALTH HISTORY
Present physical condition:________________________________________________________
Height: ___________ Weight: ____________ Status of Vision: __________________________
Is child currently under a doctor’s care? ______________ If yes, please explain. _____________
Has your child had a recent physical exam? _______ What were the results? ________________
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Has you child ever been hospitalized? ____If “yes”, for what condition(s)?__________________
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What, if any, medications is your child presently taking, and for what condition(s)? ___________
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Does child have any other medical problems? _________________________________________
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Has child ever had a neurological examination?________________________________________
If so, for what condition___________________________________________________________
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Physician’s Name & Address:______________________________________________________
Check any medical/learning condition(s) that the child has experienced.
_____ Vocal Nodules
_____ Allergies
_____ Cerebral palsy
_____ Ear Infections
_____ Learning Disability _____ Cleft palate
_____ Loss of Voice
_____ Autism
_____ Birth defect
_____ Seizures
_____ Head Injury
_____ Attention Deficit Disorder
_____ Down Syndrome
_____ Auditory Processing Disorder
_____ Hearing loss
_____ Pervasive Developmental Disorder
_____ Tourette’s Syndrome
Has your child had ear tubes? _______ If so, when and for how long?____________________
V. DEVELOPMENTAL HISTORY
At what age did the following occur?
Child sat alone without support: __________________
Child pulled up to a standing position: _____________
Child walked without assistance:__________________
Child was bladder trained: ______________________
Child was bowel trained: _______________________
Check if your child:
____ prefers right hand
____ prefers left hand
____ falls or loses balance easily
_____ shows awkwardness in using hands
_____ has difficulty chewing, eating, or swallowing
_____ has difficulty walking, running, jumping, etc.
Compared to other children your child’s age, describe how your child is able to move, play, or
learn. _______________________________________________________________________
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VI. SPEECH, LANGUAGE, AND HEARING HISTORY
During your child’s first year of life, other than crying, would you say that your child was:
_____ a very quiet baby _____ an average noisy baby
_____ a quiet baby
_____ a noisy baby
_____ a very noisy baby
At what age did your child say his or her first words? _______________________________
What were first words? _______________________________________________________
Did your child ever start talking, and then stop? __________ If yes, please describe.
___________________________________________________________________________
Which way of communicating does your child demonstrate most often?
Using sounds __________________ Using one or two words _____ Using phrases________
Using complete sentences ________ Using gestures ____________.
Please give examples of what your child might say or do to ask for a favorite food or drink:
____________________________________________________________________________
At what age did your child use word combinations like “want cookie” or “me go”?
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At what age did your child use more complete sentences like “Mommy go shopping”?
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How does your child’s voice sound? Normal __________ Too-high pitched ___
Too-low pitched ___ Hoarse ___________ Nasal ___
Does your child hesitate, get stuck, or repeat sounds or words? _________________________
Does your child have difficulty making particular speech sounds? _______________________
Which ones? _________________________________________________________________
Approximately what percentage of the time can your child be understood?
By parents: __________
By siblings: ____________
By playmates: ________
By strangers: ___________
Does your child appear to be aware that he or she speaks differently than other
children? ______ If yes, please describe. _________________________________________
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Does your child seem to have any difficulty hearing? _________________________________
Does his/her hearing appear to vary sometimes?_____________________________________
Does he/she hear less when he/she has a cold? ______________________________________
Has your child ever worn a hearing aid? ___ Which ear? ____ For how long? ____________
Why did your child stop wearing the hearing aid? ___________________________________
Does your child seem to have any difficulty understanding the speech of others or
following directions? ___ Please describe. _________________________________________
VII. FAMILY HISTORY
Father’s Name: ________________________________ Phone: ________________________
Education: __________________________ Occupation: _____________________________
Employer: ___________________________________________________________________
Mother’s Name: _______________________________ Phone: ________________________
Education: __________________________ Occupation: _____________________________
Employer: ___________________________________________________________________
9/2012
Brothers and Sisters:
Name: _______________________________________________ Age: __________________
Name: _______________________________________________ Age: __________________
Name: _______________________________________________ Age: __________________
Others living in the home: _______________________________________________________
VIII. EDUCATION AND INTERESTS
A. 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? _______________________
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Any additional information you would like to share about preschool? ______________________
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Does your child have any specific interests? ______ If so, please explain. __________________
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Are you concerned about any behavioral problems? Yes No. If yes, please explain.
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B. 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?_____________________________________________________
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?____________________
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Any additional concerns regarding your child’s school performance?_______________________
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Are you concerned about any behavioral problems? Yes No If yes, please describe.__________
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Does your child have any particular interests or hobbies? ______ If so, please describe.________
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VIIII. 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):_____________________________________________________________
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Name: __________________________________ Address: ______________________
Profession: _________________________ Date(s) of consultation: ________________
Outcome(s):_____________________________________________________________
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Name: __________________________________ Address: ______________________
Profession: _________________________ Date(s) of consultation: ________________
Outcome(s): ____________________________________________________________
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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 communication difficulty. Enclosed is a form for giving us permission to
request reports from and send reports to these professionals. Please complete and return
with this case history form.
Longwood Center for Communication, Literacy, and Learning
PO Box 513
Farmville, VA 23901
9/2012