Sample Case History Form
Sample Case History Form
Age
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of school child attends:______________________________________________________
Any special education services? If yes, explain._______________________________________
______________________________________________________________________________
What language(s) does the child speak? What is the primary language?____________________
With whom does the child spend most of his/her time?__________________________________
Describe the childs speech and language problem._____________________________________
______________________________________________________________________________
______________________________________________________________________________
What do you think caused the problem?______________________________________________
______________________________________________________________________________
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Yes
No
No
No
No
If yes, explain.__________________________________________________________________
Has any other speech-language specialists seen the child? Who and When? What were there
conclusions/suggestions?_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are there any other speech, language or hearing problems in your family? If yes,
describe.______________________________________________________________________
______________________________________________________________________________
Prenatal/Birth History
Describe mothers general health during pregnancy.____________________________________
______________________________________________________________________________
______________________________________________________________________________
Were there any unusual conditions that may have affected the pregnancy or birth? ___________
_____________________________________________________________________________
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Medical History
Describe and provide approximate age at which the child suffered the following illnesses and
conditions.
Allergies
Asthma
Chicken Pox
Colds
Convulsions
Croup
Dizziness
Draining Ear
Ear Infections
Encephalitis
German Measles
Headaches
High Fever
Influenza
Mastoiditis
Measles
Meningitis
Mumps
Pneumonia
Seizures
Sinusitis
Tinnitus
Tonsillitis
Other
Developmental History
Provide approximate age at which the child began to do the following activities:
Crawl
Sit
Stand
Walk
Feed Self
Dress Self
Use toilet
Use single words (ex. No, mom, doggie etc.)
Yes
No
Yes
No
Yes
No
Yes
No
Engage in conversation
Yes
No
Does the child have difficulty walking, running or participating in activities which require small
or large muscle coordination?______________________________________________________
Describe the childs response to sound.______________________________________________
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Educational History
How is the child doing academically?_______________________________________________
_____________________________________________________________________________
How does the child interact with others (ex. shy, aggressive, uncooperative)_________________
____________________________________________________________________________
If enrolled for special education services, has an individual education plan been developed? If
yes, describe the goals. _________________________________________________________
_____________________________________________________________________________
Please provide any additional information that might be helpful in working with your child.
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