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Blue Ridge Speech & Hearing Center

Improving Quality of Life
through Communication

Home > Forms > Pediatric Case History Form for Speech/Language Pathology

Pediatric Case History Form for Speech/Language Pathology

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Please fill out this form as completely as possible. The information will help us understand your child's present communication problems and will aid us in planning appropriate testing procedures. ALL INFORMATION IS STRICTLY CONFIDENTIAL. PLEASE INFORM US IF AT ANY TIME THIS INFORMATION CHANGES.

*PLEASE NOTE: AFTER COMPLETION, PLEASE SUBMIT ANY OTHER PERTINENT ACADEMIC/MEDICAL REPORTS (e.g. IEP's, Hospital discharge summaries) TO THE CENTER AT LEAST (1) WEEK BEFORE THE SCHEDULED EVALUATION.

I. Case Information

   
Male Female
   
Single Married Divorced Widowed
Primary Language Spoken in the Home  
Word of mouth Phone Book/Yellow Pages School System Internet Physician/Pediatrician Other

II. Family History

Are there any incidences of any of the following conditions among the child's family/close relatives (maternal and paternal)?
  Y N Explain
1. Speech problems
2. Hearing problems
3. Learning disabilities
4. Seizures/convulsions
5. Mental retardation
6. Autism/spectrum disorder

III. Birth History

Yes - Please explain No

Yes No - Please explain

  Yes No
The baby experienced difficulties breathing at birth:
The baby was described as a "blue baby":
The baby experienced some jaundice:
The baby was placed on a feeding tube:
Mother and infant were discharged separately from hospital:

 

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