Speak Up Speech Oregon | Ashley Johnson | Case History Questionnaire

Child's Name*

Date*

Parent's Name*

Phone (Cell)*

Phone (Work)

Email*

Preferred Method Of Communication for Appointment Reminders*

Cell Phone
Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

REASON FOR REFERRAL

What prompted you to refer your child for a speech and language evaluation?

What concerns do you have with your child’s communication?

When did you first notice a problem?

PREGNANCY AND DELIVERY

Any complications during pregnancy and delivery?

Did your child stay in the NICU? If yes, for how long?

HISTORY

Is there a family history of speech/language problems?

Does your child have a remarkable medical/developmental history?

Is your child on any regular medications?

Has your child suffered from any concussions or head bumps that required a doctor’s visit?

Has your child has his/her hearing and vision checked? Last screening dates? Are either hearing or vision of concern?

ARTICULATION

Can you understand what your child says? Describe what his/her speech sounds like. (i.e. unintelligible, garbled, mumbled, soft, broken/incomplete etc.)

Can someone who is not familiar with your child understand him/her?

How does your child react when he/she is not understood? Will he/she try to communication a message differently if need be?

Does your child seem aware of his/her communication differences? Does he/she express frustration at not being understood?

ORAL MOTOR/FEEDING

Do you have any concerns regarding feeding/drooling?

Does your child have a history of feeding difficulties (reflux, aversion, etc)?

Does your child suffer from sleeping issues? (enlarged adnoids?)

Does your child have any food allergies?

LANGUAGE

Does your child understand you when you talk to him/her?

Does your child follow simple 1-2 step verbal directions?

Does your child use jargon (nonsense words)? Can you understand the content of what your child is saying to you?

Does your child put multiple words together when communicating? (provide examples)

Does your child use inflection in his speech to show that he/she has communicative intent?(i.e. Does the pitch change when your child speaks?)

How does your child express his/her wants/needs? How does your child communicate? (words, gestures, signs, pictures, etc)

DAYCARE/SCHOOL

Does your child attend a daycare/school? If so, where? What days/times?

If so, does your child behave the same way at daycare as he/she does at home?

Does your child follow a routine well?

How much time does your child spend with other children?

PRIOR THERAPY-SERVICES

Does your child receive any other therapy at this time?

Has your child received OT, PT, behavioral etc. therapy in the past?

Did you child receive EI services?

How much time

If Yes, where and with whom?

If so, how beneficial was it for your child?

BILINGUAL QUESTIONS (if applicable)

How long has your child lived in the US?

What is your child’s primary language?

What language does your child prefer to speak?

Does your child have the same difficulties speaking in both languages?

Please explain:

ANYTHING ELSE?

Is there any other information you would like me to know about your child?

CONSENT

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