Case History Form
Please fill out the necessary information below. To be filled up by the patient's legal guardian.
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age/Sex
*
Medical Diagnosis
*
Developmental Pediatrician
Referring Professional
Date of last DevPed visit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
*
09 12-345-6789
Format: (09) 00-000-0000.
Email Address
example@example.com
Facebook Profile
fb.com/sample
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you consent of audio/video recording of the assessment session
*
Yes
No
Does the child go to school?
*
Yes
No
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Background Information
Father's Name
*
First Name
Last Name
Occupation
*
Mother's Name
*
First Name
Last Name
Occupation
*
Legal Guardian's Name (if applicable)
First Name
Last Name
Occupation
Who does the child live with?
*
Mother
Father
Siblings
Grandparents
Tito/Tita
Cousins
Other
What is the primary language in the house?
*
Describe the child's relationship with the family.
*
Does the child have a sibling? If yes, how far apart are they?
*
If none, put n/a.
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History of Speech and Language Problem
Chief Complaint
*
Who first noticed the problem?
*
How old was the child when the problem arose?
*
What do you think caused the problem?
*
What was done to solve the problem?
*
ex. Therapy, Medical intervention
How does your child communicate most of the time?
*
Gestures (e.g. pointing, pulling parents)
Sounds (e.g. grunting, speech sounds)
Single words (e.g. mine, shoe)
2-3 word combinations (e.g. want shoe, mommy car)
Sentences (e.g. i want my shoe, where is my ball?)
How often you understand your child?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How well do people who don’t know your child (e.g. strangers, unfamiliar others) understand their speech?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How often does the child understand you when you are talking to them?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Receptive Language
*
Rows
Age
Localized sound
Localized voice
Responded to name-calling
Recognized names of familiar persons and objects
Stopped to “No”
Followed 1-step commands
Answered simple questions
Expressive Language
*
Rows
Age
Vocalized pleasure
Made cooing, gurgling sounds
Babbled (mama, papa, baba)
Imitated adult sounds
Said first word/s (what specific word?)
Said 2-word phrases (what specific phrase?)
What are your goals for the child for Speech therapy sessions?
*
How does the child PRESENTLY communicate? Does the child use the following (answer with Yes/No and provide examples):
*
Rows
Skills
Specific Gestures
Non-specific Gestures
Sounds
Words
Phrases
Sentences
How does the child show understanding of the adults’ way of communication?
*
Rows
Skills
Does the child answer when he/she is talked to?
Does the child talk about what he/she is doing?
Does the child ask for help?
Does the child talk about past or future events?
Does the child understand you?
Describe the family’s level of understanding of the child’s way of communication.
Describe the adults’ mode of communication with the child.
How does the child interact with similar aged peers?
*
What does the child like to do at home?
*
What toys/activities does the child like to use/do?
*
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Post Natal History
Mother's Age during pregnancy
*
Length of Pregnancy (in months)
*
Type of Delivery
*
Conditions reported after Delivery
*
What was the child's birth weight?
*
*
Rows
Yes
No
Other Remarks
Any history of illness, allergies or accidents during the mother’s pregnancy?
1
2
Any history of drugs, alcohol and tobacco use during the mother’s pregnancy?
3
4
Any difficulty at time of birth?
5
6
Any complications during delivery?
7
8
Was the child delivered full term (9 mos.)?
9
10
Was the child crying upon delivery?
11
12
Was the child moving or kicking upon delivery?
13
14
What color was the child upon delivery?
*
Blue
Pale
Reddish/Pinkish
Other
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Medical History
Has your child has/have any of the following?
*
Rows
Yes
No
Other Remarks
Vision Problem
15
16
Frequent ear infections/colds
17
18
Nursing/feeding difficulties
19
20
Unusual eating habits
21
22
Seizures
23
24
Hearing Problem
25
26
Head Injury
27
28
Surgery
29
30
Asthma
31
32
Serious Illness/accidents
33
34
Other medical condition to be concerned with?
*
Aside from what was stated above.
Has the child undergone any hearing screening test? If yes, what were the results. If no, what was the reason?
*
Has the child ever been hospitalized? If yes, when and for what reason?
*
If no, put n/a.
Does your child take any medications? If yes, kindly list them down:
*
If no, put n/a.
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Developmental History
Describe the child’s gross motor development
*
Rows
Age Acquired
Held head up while lying on stomach
Rolled over alone
Crawled
Stood alone
Walked alone
Fed self with spoon
Completely toilet-trained
Established handedness
State the child’s post-natal history
*
Rows
Answers
How is/was the child fed?
What previous illnesses did the child have?
What previous medical tests and/or procedures did the child undergo and when?
What present health problems may affect the child’s therapy?
What medication does the child take frequently? How often?
Previous Interventions
*
Rows
Yes
No
When?
Focus of Intervention
Occupational Therapy?
35
36
Physical Therapy?
37
38
Speech and Language Therapy?
39
40
What improvements have you noticed?
*
Did your child have/had any feeding difficulties growing up? If yes, kindly describe them.
*
Feeding
*
Rows
Yes
No
Does the child drool while eating?
41
42
Are they able to chew with their mouths closed?
43
44
Does the child experience nasal regurgitation during feeding? (solids or liquids)
45
46
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Educational History
School Name
*
Grade and Level
*
Type of School
*
Regular
SPED
Other
Current Teacher's Name
*
First Name
Last Name
State the child's education history
*
Rows
Grade Level
School
Time Period
Observations/Remarks
1
2
3
4
5
Submit
Should be Empty: