Child Speech-Language Case History

Speech and Hearing Clinic (480) 965-2373 PO Box 870102 Fax: (480)965-0076 Tempe, AZ 85287-0102

Apps: ASU Peer Program for Socialization Case History and Registration

Today’s Date: ___/___/____ Month/Day/Year General Information

Client Name: ______Date of Birth: ___/___/______Male ___Female Last First Middle Month/Day/Year

Parent Name: ______/______Last (mother) First Last (father) First Address: ______Street/P.O. Box City State Zip

Telephone: ______Home Work Cell

Email address: ______

List people in your household. Name Relationship Age

What languages do you speak? ______

If more than one, which is your primary language? ______

List hobbies and social activities.

Name of person filling out this questionnaire: ______Relationship to client: ______

Statement of the Problem

Describe the nature of the communication or socialization problems. When was the problem first noticed and by whom?

How has the problem changed since then?

What have you done to treat the problem?

How has the problem affected your life?

Describe any specific communication situations that present difficulty for you.

Please list any additional information that you think may be helpful in assisting with your problem.

Previous Related Testing

Please list the information regarding the most recent exams below: Types of exam Date Names of Professionals Results & Recommendations Speech and Language

Hearing Test

Psychological or Neuropsychological Examination Other:

Describe any previous speech language therapy, if received. Name of Professional Duration Goal(s) Results Reason for Termination

Educational History

Please list your most recent information. Name of School Dates Attended Outcome

Medical History

Describe your present health: ____ Good ____ Fair ____ Poor

Describe any major illnesses, accidents, injuries, operations, and hospitalizations (include age) experienced. Incident Date or Age

List all medical diagnoses, including date of diagnosis and professional making diagnosis. Diagnosis Date Name of Professional

Describe any medical treatment you are currently receiving.

Provide names and dosage of any medications that you are currently taking. Medication Name Dose Strength Date Started Please list the information regarding the most recent medical exams below: Type of exam Date Names of Professionals Results Physical exam Vision Test Other:

Do you wear: ____ Hearing Aid ____ Glasses