TEACHER CASE HISTORY FORM
A Speech Pathology teacher case history form
TEACHER CASE HISTORY FORM
The purpose of this case history form is to collect as much detail as possible on the student’s progress in the classroom to date. Greater detail will aid a deeper and quicker understanding of their learning and speech pathology needs. Please feel free to contact me should you have any questions. Thank you for your time in completing this form.
Please comment on the student’s ability in the following areas:
Ability to learn curriculum / progress in classroom to date:
Ability to follow instructions / directions in the classroom:
Ability to complete tasks independently:
Does the student ask for help when he/she has not understood?
If no, what does the student do?
Ability to use clear and understandable speech (ie. Speech sounds):
How does the student cope if others do not understand him/her?
Does the student readily volunteer information in the classroom?
Ability to use language in the classroom? Please comment on the student’s ability to explain, describe, report etc, use of correct grammar, conversational abilities.
Ability to develop literacy skills:
Ability to use social communication skills (ie. Interaction with peers / adults, use of eye contact, sticking to the topic of conversation etc):
Ability to participate in playground interactions (ie. Does the student play appropriately? Does the student have an appropriate peer group? Can the student participate appropriately in a variety of activities? Does the student experience any difficulties during playtimes?)
Areas of concern at present? (ie. please list any factors affecting the student’s ability to fully participate in classroom learning)
Do you know if student has been seen by any of the following professionals at school or outside school?
Ear, Nose and Throat Specialist
Speech and Language Skills
Does the student display difficulties in any of the following areas at home?
Understanding spoken language ?(eg. Instructions, jokes, stories etc)
Understanding written language ? (eg. Written stories, text etc)
Producing spoken language ? (eg. Explaining, describing etc)
Using speech that can be understood ? (eg. Sound errors in speech)
Literacy development ? (eg. Reading / writing / spelling)
Voice problems ? (eg. Harshness, croaky, looses voice)
Social skills ? (eg. Eye contact, sticking to topic of conversation etc)
Organisational skills (eg. Handing in work in time, using a diary etc)
What are your goals for this student?
Any other relevant information? (eg. family breakdown, illness or stress)
Should be Empty:
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