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When and how did the difficulty begin? Did the problem begin suddenly or gradually? 3. How would you rate the severity of the problem now? Mild Moderate Moderately Severe Severe. 4. Describe what you think may have caused this problem, and/or any situation or condition that you associate with this problem. 5.
When was the problem first noticed? Has the problem changed since it was first noticed? Have any other specialists seen the child? If yes indicate the type of specialist, when the child was …
CHILD/ADOLESCENT CASE HISTORY FORM . To assist us with learning more about your child’s communication skills, please complete the following form. Write NA in the questions that do not apply to your child. INTRODUCTION . Child’s Name_____ Birthdate_____ Sex _____
Speech Assessment Case History Form (page 4) Speech & Language Development Indicate the approximate age at which your child reached the following milestones: Babbled Put two words together Said first words Spoke in short sentences YES NO Unsure Was your child a quiet infant (limited vocalizations/babbling)? . . . . . . . .
Please indicate if your child has a family history of the following problems: (__) hearing (__) speech (__) learning (__) language (__) reading If so, please explain: _____ _____
Thank you so much for your cooperation in completing this form, it is crucial that we have this information so that we can provide the most effective evaluation and therapy services for your child.
Aug 15, 2022 · (1) Please describe pregnancy and birth history (i.e. complications, type of delivery, prematurity, etc.). (2) Please describe any developmental problems experienced during infancy or early childhood (i.e.
Developmental History Please tell the approximate age your child achieved the following developmental milestones: _____ sat alone _____ grasped crayon/pencil _____ babbled …
Are you currently receiving or have you received speech therapy in the past? If so, please describe your experience and your age(s) when you received therapy: . When was the disfluency first noticed? By whom? What do you believe caused the onset? Are there any periods (days, weeks, months) when stuttering either increases or decreases?