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Speech-Language-Hearing Case History Questionnaire - complex yes no questions speech therapy


Speech-Language-Hearing Case History Questionnaire-complex yes no questions speech therapy

Speech-Language-Hearing
Case History Questionnaire
Child Lives With:
Birth Parents Foster Parents Other
Mother Father
Adoptive Parents Parent and Step-parent
Does child have siblings? ______ Yes ______ No
If yes, how many? _______________________________________________________
Family History of Speech and Language Diagnoses: ______ Yes ______No
If yes, please explain: _____________________________________________________
Child's race/ethnic group:
Caucasian Hispanic African-American
Native American Asian Other
Birth History
How old was the mother when the child was born?
How many months was the pregnancy?
Were there any complications that occurred either during the pregnancy or the birth process?
Yes No
If yes, please describe.
___________
______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Did the child go home with his/her mother from the hospital? Yes No
If child stayed at the hospital, please describe why and how long.
____________________________________________________________________________
____________________________________________________________________________
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Speech-Language-Hearing
Case History Questionnaire
Medical History
Does your child have any known medical diagnosis?
Does your child have any known allergies? ____ Yes ______ No
___________________ Seasonal _________________________ Food
___________________ Latex _________________________ Dye
___________________ Medication _________________________ Other
Does your child have any dietary restrictions: ____ Yes _____ No
If yes, please explain:
____________________________________________________________________________
____________________________________________________________________________
Has your child had any of the following?
Adenoidectomy Asthma Measles
Tonsillitis Esophageal Reflux ______Mumps
Tonsillectomy ______Vocal nodules/polyps ______Chicken Pox
Frequent colds Seizures Encephalitis
Sinusitis Head Injury Flu
Ear infections High Fever Vision problems
Ear tubes Scarlet Fever Sleeping difficulties
Breathing Difficulties Meningitis Xerostomia (Dry Mouth)
Other medical condition(s):
Other serious injury/surgery:
Is your child currently (or recently) under a physician's or specialist's care? ____Yes ____No
If yes, why?
Please list any medications your child takes regularly:
Has your child been or is he/she currently under the care of an orthodontist? ____Yes _____No
If yes, Please explain
____________________________________________________________________________
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Speech-Language-Hearing
Case History Questionnaire
Developmental History
Please tell the approximate age that your child achieved the following developmental
milestones:
_____Sat up _____Used Single Words
_____Crawled _____Combined Words
_____Stood _____Fed Self
_____Walked _____Dressed Self
_____Babbled _____Toileted
Behavioral Characteristics
Cooperative Attentive
Willing to try new activities Plays alone for reasonable length of time
Separation difficulties Easily frustrated/impulsive
Stubborn Restless
Poor eye contact Easily distracted/short attention
Destructive/aggressive Withdrawn
Inappropriate behavior Self-abusive behavior
Please list specific toys or activities that motivate your child:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Hearing
Did the child pass his/her newborn hearing screen? ______ Yes ______No
Do you feel your child has a hearing problem? ______ Yes ______No
If so, please describe: _________________________________________________
_________________________________________________________________________
Has he/she ever had a hearing evaluation/screening? ______ Yes ______No
If yes, where and when? _______________________________________________
What were you told? _____________________________________________________
____________________________________________________________________________
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