Initial Case History Form

Jill Carter Marshall M.A.
CCC/L SLP
Speech-Language Services, Evaluation and Therapy
630-297-3540
spinningslp5@aol.com
Speech-Language-Hearing Case History Form

Identifying Information:
Childs Name: ______________________________ Date of Birth: ________________
Parents Name (s): ___________________________ Home Phone : ______________
Home Address: ______________________________ Cell Phone: _________________
______________________________ Work Phone: ________________ Parents
Occupation: _____________________________________________________ Email
Address: ____________________________/ _____________________________
Childs School: _______________________ Grade: ____ Teacher: _________________
Referred By: ____________________________________________________________
Doctors Name: ______________________________ Doctors Phone: _____________
Child lives with (check one):
___ Birth Parent
___ Adoptive Parents ___ Parent & Step-parent
Family History:
Siblings: ____________________________ ____________________________
____________________________
Is there a family history of : Speech/Language Difficulties
Hearing Impairment/Deafness Learning Difficulties Developmental Difficulties
If you responded yes to any of the above, please describe:
___ Foster Parents
___ One Parent
___ Other: ______________
Age: _______ _______ _______
Y es/No ______ ______ ______ ______
Other Language Exposure:
Is there a language other than English spoken in the home? _____ Yes _____ No If yes,
which language? ________________________________
Does the child speak this language? _____ Yes _____ No
Does the child understand this language? _____ Yes _____No
Which language does the child prefer to speak at home? _________ school? _________
Birth & Medical History:
Was there anything unusual about the pregnancy or birth? If yes, please explain:
How old was the mother when child was born? _________ How many months was the
pregnancy? _________
Was the mother sick during pregnancy? _________
Birth Weight: _________
_____ Yes
_____ No
Has your child had any of the
Adenoidectomy ____ Allergies ____

following:
Breathing Difficulties Chicken Pox
Frequent Colds
Frequent Ear Infections ____ Ear (PE) Tubes ____
If you checked any, please provide details/dates:
____ ____ ____
High Fevers
Head injury
Sleeping Difficulties ____ Thumb/Finger Sucking ____ Tonsillectomy ____ Tonsillitis
____ Vision Problems ____
____ ____
Other serious illness/injury: ________________________________________________
Date of last hearing screening: ______________ Results: _______________________
Date of last vision screening: ______________ Results: _______________________
Hospitalizations: _________________________________________________________
Medications: _________________________________________________________
Developmental History:
Please tell the approximate age your child reached the following milestones:
_________ Sat Alone
_________ Babbled __________Said first word(s) __________Spoke in short sentences
__________Completed toilet training
Oral Motor & Feeding History:
__________ Grasped crayon/pencil __________ Crawled
__________ Put two words together __________ Walked
Has your child experienced feeding/eating difficulties (e.g., biting, swallowing,
chewing)? Yes/No _______ If yes, please explain:
_____________________________________________________
Was your child breast-fed or bottle-fed? _______________________________________
Does your child eat by self using utensils? Yes/No ______ Drool? ______
Does your child put toys in mouth? Yes/No ______
If yes, please explain: _____________________________________________________
Does your child have food allergies? Yes/No ______
Does your child have food preferences/aversions? Yes/No __________
Speech & Language Development:
How does your child prefer to communicate?
_______ gestures _______ words _______ both _______ neither
Number of words in a typical sentence? ______________________________ Is your
childs speech difficult to understand? ______________________________ What types
of speech errors does he/she exhibit?
Does your child: identify objects? ________ actions? _________
ask questions? ________ follow directions? _________
understand what you are saying? _________

respond correctly to yes/no questions? ________
respond correctly to WH (who, what etc.) questions? ________
Please provide examples of your childs speech/language:
Has your child ever received a speech/language evaluation? Yes/ No _____ Date______
Has your child received speech/language therapy previously? Yes/No _______________
If yes, when? For how long? _______________________________________________
Can your child have food for therapy and/or rewards? Yes/No ____________________ If
yes, please list any exceptions: ____________________________________________
Please indicate your current concerns:
Is your child aware of, or frustrated by, any speech/language difficulties? ____________
What do you see as your childs most difficult problem in the home?
What do you see as your childs most difficult problem in school?
School History:
Has your child ever repeated a grade? _____ If so, what grade? ________
What are your childs strengths and/or best subjects? _________________
Is your child having difficulty with a particular subject? ______________
If yes, what subject? ___________________________________________
Is your child receiving help at school or at home (i.e., support services, tutoring, etc.)?
Yes/No:______ If yes, please explain: ____________________________________
Favorite Activities:
Please list your childs favorite activities, hobbies, toys, games places, people, characters,
etc.
________________________________________________________________________
________________
________________________________________________________________________
________________
________________________________________________________________________
________________
________________________________________________________________________
________________
Additional Concerns/Comments:

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Jill Carter Marshall M.A.

Speech-Language-Hearing Case History Form

Adenoidectomy Allergies

understand what you are saying? _________

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