FULP THERAPY SERVICES, INC. - Communication Specialists for Children
Case History Form
 
Child's name______________________________DOB___________________________________
 
Home address_________________________________phone______________________________
 
Name of parent(s)_________________________________________________________________
 
Mom's cell/work____________________Dad's cell/work__________________________________
 
How did you find out about us?___________________________________________________
 
 
Please list any pertinent medical and/or developmental diagnoses__________________________
 
________________________________________________________________________________
 
Please describe your child's speech-language problem  ___________________________________
 
________________________________________________________________________________
 
________________________________________________________________________________
 
How long have you been aware of the problem?_________________________________________
 
Who first noticed the problem?______________________________________________________
 
What attempts have been made to help your child?______________________________________
 
________________________________________________________________________________
 
Please describe any difficulties you may have experienced during your pregnancy and/or your
 
child's birth______________________________________________________________________
 
________________________________________________________________________________
 
Did your child require any NICU services?______________If yes, please explain______________
 
________________________________________________________________________________
 
Developmental history-Please list age attained
 
crawling__________          sitting independently__________
 
walking__________           feeding self__________
 
toliet trained__________
 
 
Please list medical professionals involved in your child's care
 
                                        Name                Location               Dates
Doctor
 
ENT
 
Neurologist
 
Speech Pathologist
 
Occupational Therapist
 
Physical Therapist
 
CDSA
 
Please list the people who live in your home
 
Name______________________Age_______Occupation________________
 
Name______________________Age_______Occupation________________
 
Name______________________Age_______Occupation________________
 
Name______________________Age_______Occupation________________
 
Name______________________Age_______Occupation________________
 
Name______________________Age_______Occupation________________
 
At what age did your child achieve the following:
 
  • saying simple words such as mama, dada, baba_____________________________________
 
  • saying the names of family members______________________________________________
 
  • putting two words together_______________________________________________________
 
  • using phrases and sentences____________________________________________________
 
How many words does your child currently use?________________________________________
 
Please give examples if less than 20 words____________________________________________
 
________________________________________________________________________________
 
Once your child started talking, did he/she add new words on a consistent basis?____________
 
How often did you child add new words?_______________________________________________
 
Did your child's speech development ever seem to stop for a period of time?_________________
 
How did you communicate with your child during this time?_______________________________
 
________________________________________________________________________________
 
Does your child ever sound like he/she is stuttering or hesitant with his/her speech?___________
 
Please explain___________________________________________________________________
 
_________________________________________________________________________________
 
Does your child frequently repeat words and/or sentences he/she hears others say?____________
 
Please explain____________________________________________________________________
 
_________________________________________________________________________________
 
Does your child repeat TV commercials, parts of movies, etc. in a rote manner of speech?_______
 
Please explain____________________________________________________________________
 
________________________________________________________________________________
 
Does your child have difficulty following directions?_______________________________________
 
Please explain____________________________________________________________________
 
Does your child play with toys in a normal manner?______________________________________
 
Please explain____________________________________________________________________
 
Describe any concerns you have regarding your child's behavior____________________________
 
_________________________________________________________________________________
 
Describe any specific fears your child may have_________________________________________
 
How much time does your child spend with other children_________________________________
 
What are your child's favorite toys, books or activities?____________________________________
 
_________________________________________________________________________________
 
Please list any allergies your child may have____________________________________________
 
How are allergies treated?___________________________________________________________
 
Does your child snore?__________Is your child a picky eater?_____________________________
 
Does your child appear to have a preference for certain types of foods?_______________________
 
If so, what are they?________________________________________________________________
 
Does your child tend to "stuff" mouth when eating?_______________________________________
 
Please list any illnesses, surgeries, hospitalizations your child has had______________________
 
_________________________________________________________________________________
 
_________________________________________________________________________________
 
Please list any medications and/or dietary supplements your child may take__________________
 
_________________________________________________________________________________
 
_________________________________________________________________________________
 
Is there any family history for speech, language, hearing, reading and/or ADHD?_______________
 
If yes, please give details____________________________________________________________
 
_________________________________________________________________________________
 
_________________________________________________________________________________
 
Name of child's school or preschool___________________________________________________
 
Please list days/times your child is available for speech therapy____________________________
 
_________________________________________________________________________________