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1. CHILD CASE HISTORY FORM:-
DEMOGRAPHICS
GENERAL INFORAMATION DATE: ____________
CHILD’S NAME: ________________________ D.O.B:____________
AGE: ________ ADDRESS: ____________________________________
PHONE: ______________ CITY: ____________
EMAIL: ____________________________________
Does the child live with both parents? __________
MOTHER’S NAME: __________________ AGE: ___________
MOTHER’S OCCUPATION: _________________________
FATHER’S NAME: _________________ AGE: _ __________
FATHER’S OCCUPATION: _____________________
Brothers and sisters (includenames and ages)
Name Age
1. Describethe child’s speech-languageproblem.
___________________________________________________________________
__________________________________________________
2. What language does the child speak? Whatis the child’s primary language?
__________________________________________________________________

2. 3.Whatlanguages are spoken in the home?
___________________________________________________________________
4. With whomdoes the child spent mostof his or her time?
___________________________________________________________________
5.How does the child usually communicate(gestures, singlewords ,shortphrases
,sentences)?
___________________________________________________________________
6.When was the problem firstnoticed?
___________________________________________________________________
7.Arethere any other speech language or hearing problems in your family? If yes
please describe.
___________________________________________________________________
PRENATAL AND BIRTH HISTORY:
Mother’s general health during pregnancy (illness, accidents, medications, normal
etc).
During pregnancy was mother exposed to antibiotics? Yes / no
How long was pregnancy? _________________months.
Any problems with pregnancy or delivery? Yes / no
PERINATAL HISTORY:
Any problem with pregnancy or delivery? Yes / no
Birth weight: _______________ (prematureor healthy)
Birth was: normal labor pain prolonged.
Did the child cry after delivery? Yes / no (if yes then early/delay)

3. POSTNATAL HISTORY:
Did the infant has any of the following?
Allergies Cold High fever Pneumonia
Asthma Influenza Draining ear Infection
Cyanosis Ventricular septal defect orofacial clefts
Mouth and facial defects
Was your child in the Neonatal intensive care unit (NICU)? Yes / no
If so then how for long and why?
_____________________________________________________________
Any problem with feeding ( sucking/swallowing)?Yes / no
DEVELOPMENTAL HISTORY:
Developmental history providethe approximate age at which the child begin to
do the following activities:
Milestones: delayed/in time/ early
Crawl: __________ Sit: _________
Stand: _____________ Walk: ___________
Feed self: ___________ Use toilet: _________
Use single words (e.g no, mom, doggie) _______________
Combine words (e.g me go, daddy shoe,etc) _________________
Name simple objects (e.g dog, car, tree etc) _____________
Use simple questions (e.g whereis the book?) ________________
Engage in conversation: _______________________
Describethe child responseto sound e.g respond to all sounds , responds to loud
sounds only? Yes/no

4. EDUCATIONAL HISTORY:
School:
Grade:
How is the child doing academically?
___________________________________________________________________
____________________________________
How does the child interact with others (e.g shy , aggressive , uncooperative etc)?
PERSON COMPLETING THIS FORM:
RELATIONSHIP TO CHILD :_________________
SIGNATURE: ____________________