Case History

Case History Questionnaire

Please fill out the form below for our records.

Date / Time

Childs Name *

First

Last

Parents Name *

First

Last

Phone

Email *

Address

Address Line 1

City

State / Province / Region

Postal Code

Reason for refferal

Source of referral: (if CDM, please make sure your doctor has signed the documentation and bring to the first appointment)

Has your child ever seen a SP before?

Siblings?

Family history

Birth History

Pregnancy

Delivery

Birth weight

Special needs

Feeding History

Breast or bottle fed

Solids

Problems chewing

Drooling

Thumb sucking

Dummy

If YES (to what age, how many hours per day: bedtime / all day?)

Motor Milestones

Crawling

Walked at

Well-coordinated?

Language Milestones

Babbling

First Words at

Sentences at

Have there ever had any concerns re language skills?

Has your child’s speech always been clear?

Medical History

Illnesses/injuries

Hospitalisation

Medication

Audiology

Formal hearing assessment

History of ear infections

Other services/specialists

(Stuttering)Fluency: Please provide details

• family history • what type of stutter (does he stutter at the beginning of sentences/]? Does he/she try to say something and nothing comes out?) etc • when is it worse? (e.g. tired/ excited).