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Home | Forms(to print-scroll to bottom of form) Patient History Information Community Speech and Hearing Center
PATIENT HISTORY INFORMATION ________________________________________________________________________ Father's name:__________________________________ Age:_______________________ Address:__________________________________________________________________ Occupation:______________________________ Business phone:(___) ______-__________ Employer:________________________________________________________________ Address:__________________________________________________________________ Health: Good Fair Poor Education completed_____________________________ Please list all children in family from oldest to youngest: Name: Age: General Health:
Do any of the other children have special problems?__________________ Please Describe: ______________________________________________________________________ Are any of the children adopted?______________________________________________ Others living at home: Name: Age: General Health:
Is there any other language than English spoken in the home?__________________________ Have there been any changes in the family group (such as death, divorce, frequent change of address, prolonged absence or illness of either parent, ect? Please Describe:_____________ _______________________________________________________________________
Weight of child at birth:_________________ Delivered at full term?____________________ If not, how many weeks premature?:____________________________________________ Did any of the following occur in relation to pregnancy or birth?
Please Describe:___________________________________________________________ Type of Delivery:__________________________________________________________
Early Feeding History Did/does your child drool when eating?__________________, when sucking a sweet _______, making sounds _____________________________________________________________. Did/does your child have difficulty with any of the following while feeding? Tongue thrust ____________, Gagging _______________, Continual Sucking ____________, Inability to close mouth _________________, Swallowing ____________, Biting a piece of food ___________, Chewing _______________, Resisting eating ______________________.
Did/does s/he have difficulty closing lips to get food off spoon or fork?____________________. Did/does s/he do this with teeth or lips?___________________________________________. Did/does s/he have difficulty with certain foods?_____________________________________.
Where/are there difficulties when your child drank/drinks?_____________________________. Please Describe: ___________________________________________________________.
Developmental History. Give an age of development: Sitting _______________ Eating solid foods________________ Crawling _________________ Standing Alone _______________Walking _______________ Drinking from a cup __________________________________________________________ Do you feel your child have any difficulties with coordination: Of Hands _______Of Feet ______ Please Describe: ___________________________________________________________. Which hand is preferred? _____________________________________________________ Present weight: ___________________________ Height:____________________________
Date
of last medical examination:
________________________________________________
Is your child subject to frequent colds or sore throats? ____________ If yes, age of onset: ___________ How many? _____________ What was the form of treatments? _______________________________________________________________ Has s/he had allergies, asthma, hay fever, ect.? _____________________________________ Does s/he tend to breath with mouth open? ________________________________________ Does your child hear? ________ If not formally tested, please describe how you know:___________________________________________________________________
Has your child been formally tested? _____________ When? _____________ Results:__________________________________________________________________
Does your child have any visual problems? _____________ Please Describe:
Have tonsils and adenoids been removed? ______________ When? ___________________ Has your child had any other surgeries? _______________ Please Describe:
Does s/he complain of aches, pains, headaches, stomachaches? __________ Please Describe:
Has your child had examinations by any of the following specialists?
Please indicate name of Doctor, date of visit, and results:
Speech and Language History How old was the child when s/he first started to use words? ___________________________ To make sentences? ________________________________________________________ At what age did you notice speech or language problems? ____________________________ Has the child had any help for this difficulty? Place Dates
Has anyone teased him/her about their speech or criticized them excessively? ______________ If so, how did s/he react? ____________________________________________________
Do you think his/her speech has changed in the last six months? ________________________ If so, how? _______________________________________________________________
What is his/her primary mode of communication?
How easy is it for you to understand your child's speech?
What do you believe is the main cause of his/her speech difficulty?
Social Personal History What is your type of residence?
Where does your child usually play? _____________________________________________ Are there any children his/her age in the neighborhood? _______________________________ Does s/he prefer older or younger children? _______________________________________ Is s/he a leader or a follower in a play? ___________________________________________ Does s/he prefer to play alone? _________________________________________________ Does s/he have a special friend? ________________________________________________ Does s/he play well with brothers and sisters? ______________________________________ Does his/her father play with the child frequently? ___________________________________ Describe the child's most frequent playmates:
How many hours a day does s/he watch TV? ______________________________________ What are your most frequent discipline problems with the child?
Who does the disciplining? _____________ How do you discipline? ____________________ ________________________________________________________________________ Have any of these nervous habits been observed?
Do any of these terms apply to your child?
Education Did your child attend a Preschool/Daycare? ______________________________________ Name of Preschool/Daycare: _________________________________________________ Address:_________________________________________________________________ Name of teacher(s):________________________________________________________ How often did child attend? __________________________________________________ Full days ________Partial Days ______AM ______PM ______How long______________ Did child seem to have any problems communicating there: _______________Please describe:
Did his/her teachers comment about his/her communication abilities? _____________________ Please describe:
Present grade: _____________ Name and address of school: ___________________________________________________ _________________________________________________________________________ Name of teacher ____________________________________________________________ Does s/he like school? _________________ Does s/he like the teacher? _________________ Are any school subjects difficult for him/her? ______________________________________ Has s/he ever skipped or failed a grade? _________________________________________ What are his/her best subjects? ________________________________________________ Does s/he attend any special classes? ____________ Please describe:
Is your child read at home? ___________________________________________________ Does your child show interest in reading at home by him/herself? _______________________ Is your child a member of any organization? ________________ Please describe:
At any time in his/her development, did any of these behaviors occur?
Briefly please describe your child's behavior, personality and social assets:
The following physician or professional is authorized to receive Community Speech and Hearing Center's evaluation results and/or other pertinent information.
_______________________________________________________ (signed)
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