Child Case History

CHILD REGISTRATION & CASE HISTORY

Please fill in as completely as you can and read the consents at the bottom of the form. Then sign and submit. All information is secure and strictly confidential.
Child's Name*

First NameMiddle NameLast Name
Home Phone Number*

Area CodePhone Number
Child's Birth Date*

MonthDayYear
Person completing this form*
Patient Gender*
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship to child (parent, teacher, etc.)*
Brief description of main problem
Who referred you to us, or how did you hear about us?
What do you hope to obtain from this evaluation?
What is the main communication goal you have for this child?
How did you hear about us?
Payment Information

Please note: We do not participate as a provider in any insurance plan. You are responsible for full payment for all services. Check with your insurance plan to determine whether your payments to BS+L for speech-language pathology services can be reimbursed.
Name of Person Responsible for Payment*

First NameMiddle NameLast Name
Responsible Person's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Responsible Person's Phone Number

Area CodePhone Number
Responsible Person's Email
Family Information
Mother's name
Mother's Cell Phone Number

Area CodePhone Number
Mother's occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Plan (so we can send text appointment reminders)
Mother's E-mail
Father's name
Father's occupation
Father's Cell Phone Number

Area CodePhone Number
Cell Phone Plan (so we can send text appointment reminders)
Father's E-mail
Where does the child live?
How many people live in this home (including the child)?
With whom does the child spend most of his/her time during the week?
Child's primary language
Child's other principal language
Is there a television in the child’s bedroom?

NoYes
How many TV sets are in the home where the child lives most of the time?
Please list other professionals currently involved with the child’s care (Psychologist, Neurologist, Speech Language Pathologist, Occupational Therapist, Ear Nose Throat Doctor, tutors, etc.)
What are the rules for this child regarding "screen time" (TV watching, use of computers, electronic games, iPods, etc.)?
Have any other Speech-‐Language specialists worked with this child? Please list names and approximate dates:
Please list any other professionals who have worked with the child in the last 3 years; indicate the reason why.
Was the child ever evaluated for Early Intervention Services or by a child study team?

NoYes
Please indicate the last date of the following (if applicable)
Hearing Test:
Vision Test:
Central Auditory Processing Evaluation:
Are there any other speech, language, learning, reading attention, or hearing difficulties in the child’s family? If yes, please describe.
PRENATAL AND BIRTH HISTORY
Was child adopted?

NoYes
Mother’s general health during pregnancy (illnesses, accidents, medications, etc.):
Please describe any complications during pregnancy / delivery:
MEDICAL HISTORY
Select all that apply

AllergiesAcquired Brain Injury (Concussion)AsthmaDizzinessEar infectionsFrequent colds (more than 6/year)High feversInfluenzaMeningitisSinusitisADD / ADHDSnoringTraumatic Brain Injury (TBI)PneumoniaFrequent or severe headachesMeasles / MumpsSeizuresTonsillitis
Describe any surgeries, major accidents, hospitalizations child has had and give dates
Is child up to date on all vaccines?

YesNo
List any medications child currently takes
Is the child allergic to any medications?

YesNo
If "yes" please list medication to which child is allergic
DEVELOPMENTAL HISTORY
Please give the approximate age in months at which the child began to do the following activities (leave blank if the answer is "not yet":
Crawl
Sit up
Stand
Walk
Feed self
Toilet trained
Dress self
Use single words: (no, mom, doggie, etc.)
Name simple objects (dog, car, tree, etc.)
Combine words (me go, daddy shoe, etc.)
Engage in conversation:
How does the child primarily communicate (gestures, single words, short phrases, sentences, conversation)?
Does the child have difficulty walking, running, or participating in activities that require small or large muscle coordination?
Describe any feeding or eating problems (e.g. problems with sucking, tolerating specific food textures, swallowing, drooling, chewing, etc.).
From what does the child primarily drink? (e.g. cup, straw, sippy cup, bottle)
Describe the child’s response to sound (e.g. responds to all sounds, tolerates loud noises, responds to loud sounds only, inconsistently responds to sounds, etc.).
EDUCATIONAL HISTORY
What grade is the child in now (if summer, what grade will the child be entering?
Name of Child's School
Where is the school (town, state)?
If applicable, does the child sit through circle time?
Has the child's teacher expressed any concerns to you?
Have you expressed any concerns to the teacher?
How is the child doing academically (or pre-‐academically)? Please comment on reading and written language.
Does the child like school?

YesNo
Does the child enjoy reading or being read to?

YesNo
Describe any special services the child receives at school.
SOCIAL HISTORY
How does the child interact with others (shy, aggressive, uncooperative, etc.)?
Does this child make friends easily?

YesNo
Does the child have more success interacting with adults than peers?

YesNo
Do you have any concerns about the child’s social skills or ability to make friends and/or to sustain friendships?
Is there anything else you would like us to know about this child that might help in the evaluation process?
How would you like to be reminded of your appointments? (Check one or more)*

Text message to cell phonePhone call to homeEmail
When would you like to be reminded of your appointment?*
I grant BS+L permission to release information about my child to these person or organizations (Check all that apply)*

Child's PediatricianChild's SchoolChilds' Otolaryngologist (ENT)Child's Psychotherapist/Counselor
Please give names and addresses for those checked above
Others to whom information about my child may be released
Today's Date

MonthDayYear
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CHILD REGISTRATION & CASE HISTORY

Payment Information

Family Information

Please indicate the last date of the following (if applicable)

PRENATAL AND BIRTH HISTORY

MEDICAL HISTORY

DEVELOPMENTAL HISTORY

Please give the approximate age in months at which the child began to do the following activities (leave blank if the answer is "not yet":

EDUCATIONAL HISTORY

SOCIAL HISTORY