Client Case History. Client s Full Name: Name by which client is called: Date of Birth: Home Address: Client s Home Phone Number: Cell Phone Number:

Transcription

1 Clint Cas History Clint s Full Nam: Nam by which clint is calld: Dat of Birth: Ag: Hom Addrss: Clint s Hom Phon Numbr: Cll Phon Numbr: What languag(s) is/ar spokn at hom? Who rfrrd you to SPEECH PATHways? What concrns bring you to SPEECH PATHways? Hav you discussd ths concrns with your child s doctor or tachr? List any mdical diagnoss th child has: What do you hop to accomplish by coming to Spch PATHways? Has your child in th past or dos h/sh currntly us an augmntativ communication dvic or any assistiv tchnology at hom or at school? Ys No If h/sh has usd in th past only, brifly xplain why h/sh is not currntly using: Who valuatd your child for th augmntativ communication dvic or assistiv tchnology? SPEECH PATHways PAGE 1 OF 15 REVISED 04/05/07

2 FAMILY INFORMATION Nam of Mothr: Languags Spokn: Addrss: Occupation: Education Lvl: Work Phon: Hom Phon: Cll Phon: Nam of Fathr: Languags Spokn: Addrss: Occupation: Education Lvl: Work Phon: Hom Phon: Cll Phon: With whom dos your child liv? (List in tabl blow) Nam Ag Gndr Spch Problm? Rmarks SPEECH PATHways PAGE 2 OF 15 REVISED 04/05/07

3 COMMUNICATION STATUS How would you dscrib th clint s currnt communication ability? (Chck all that apply.) Almost nvr communicats Somtims communicats Communicats frquntly Is vry asy for m to undrstand whn I know th topic of convrsation Is fairly asy for m to undrstand whn I know th topic of convrsation Is difficult for m to undrstand whn I know th topic of convrsation Is vry asy for m to undrstand if I don t know th topic of convrsation Is fairly asy for m to undrstand if I don t know th topic of convrsation Is difficult for m to undrstand if I don t know th topic of convrsation Is usually undrstood by othr popl who don t know him/hr wll Is usually NOT undrstood by othr popl who don t know him/hr wll In your own words, plas dscrib how your child communicats: Indicat th xtnt to which you agr with th following statmnts (circl on): Your child is abl to communicat ffctivly to xprss plasur or displasur. Strongly Disagr Disagr Not Sur Agr Strongly Agr Your child can communicat to gt hlp whn ndd. Strongly Disagr Disagr Not Sur Agr Strongly Agr Your child s biggst communication nd is to ask for things h/sh nds. Strongly Disagr Disagr Not Sur Agr Strongly Agr Your child s biggst communication priority is to gt or giv information (.g., ask or answr qustions). Strongly Disagr Disagr Not Sur Agr Strongly Agr SPEECH PATHways PAGE 3 OF 15 REVISED 04/05/07

4 What words, if any, dos your child say? What words, if any, dos your child writ? What gsturs dos your child mak (.g. pointing, motioning to com hr, and tugging for attntion)? Whn dos h/sh us ths gsturs? Brifly dscrib a typical day for your child: Plas list any of your child s achivmnts that ar spcially important to him/hr or you: SPEECH PATHways PAGE 4 OF 15 REVISED 04/05/07

5 What manual signs (or sign languag) dos your child us? Whn dos h/sh us ths signs? What othr things dos h/sh do to communicat (.g., Look at somthing h/sh wants, blinks ys)? THERAPUTIC INFORMATION Plas list som things your child rally liks and disliks: FOODS PEOPLE TV SHOWS Liks Disliks Liks Disliks Liks Disliks SPEECH PATHways PAGE 5 OF 15 REVISED 04/05/07

6 PLACES THINGS TO DO OTHER Liks Disliks Liks Disliks Liks Disliks Plas list any spcial intrsts or hobbis your child has: PRENATAL AND BIRTH HISTORY Chck any of th factors blow that apply for th Clint s Birth Mothr: During Prgnancy Excssiv vomiting Hmorrhaging X-ray tratmnts Illnsss (i.., Grman masls) Mdications RH incompatibility Drug us Smoking Prvious miscarriags Alcohol us Trauma/injuris High blood prssur Excssiv wight loss Excssiv wight gain Diabts Prmatur ruptur of Nd for hospitalization mmbrans or bd rst SPEECH PATHways PAGE 6 OF 15 REVISED 04/05/07

7 CLIENT S MEDICAL HISTORY For any conditions that apply, provid ag of onst and chck if condition is mild, modrat or svr. A g M i l d M o d S v r A g M i l d M o d S v r Allrgis Hart Problms Asthma Mningitis Convulsions / Sizurs Muscl Disordr Dntal Problms Nrv Disordr Encphalitis Pnumonia Hadachs Vision Problms Had Injuris Ear Infctions Dscrib any othr illnsss, accidnts, injuris, oprations, and hospitalizations: Dos your child us a whlchair or assistiv walking dvic? SPEECH PATHways PAGE 7 OF 15 REVISED 04/05/07

8 SPEECH AND LANGUAGE DEVELOPMENT Indicat whn your child first dmonstratd th following: Ag Bhavior Ag Bhavior Cooing, plasur sounds Singl words Babbling (ba-ba, da-da, tc.) Phrass (go by-by, mor juic Jargon (talking own spcial languag Short sntncs What is th primary mthod(s) your child uss for ltting you know what h/sh wants? Looking at objcts Pointing at objcts Gsturs Crying Vocalizing/grunting Physical manipulation Singl words 2-3 word combinations Sntncs Which of th following bst dscribs your child s spch? Easy to undrstand Difficult for parnts to undrstand Difficult for othrs to undrstand Almost nvr undrstood by othrs Diffrnt from othr childrn of th sam ag Which of th following statmnts bst dscribs your child s raction to his/hr spch? Is asily frustratd whn not undrstood Dos not sm awar of spch/communication problm Has bn tasd about his/hr spch Tris to say sounds or words mor clarly whn askd Is succssful in saying sounds or words mor clarly whn h/sh tris Is your child awar of his/hr communication difficultis? Ys No If ys, how dos this awarnss impact your child s social/motional status? Dos your child hav difficulty producing crtain sounds? Ys No If ys, which ons? Dos your child hsitat and/or rpat sounds or words? Ys No Dos your child gt stuck whn attmpting to say a word? Ys No Do you hav concrns about your child s voic? Ys No SPEECH PATHways PAGE 8 OF 15 REVISED 04/05/07

9 Which of th following do you think your child undrstands? His/hr own nam Nams of body parts Family nams Nams of objcts Simpl dirctions Complx dirctions Convrsational spch MOTOR DEVELOPMENT At approximatly what ag did your child achiv th following motor milstons? Had support Rach & grasp Sitting alon Crawling Standing alon Walking alon Climbing stairs Fingr foods Eat with a spoon Potty traind Undrssd slf Is your child ovrly awkward or clumsy? Ys No Dos your child display a hand prfrnc? Ys No If ys, which hand dos your child prfr to us? Right Lft Has your child had any fding difficultis? Chck ach itm that applis. Sucking or nursing Excssiv lngth of tim to drink bottl Rgurgitation of liquids or solids through th nos Difficulty chwing or swallowing mats Chocking and/or gagging Dos your child chok whil ating? Ys No If ys, on what foods? Is your child a picky atr? Ys No If ys, what foods dos h/sh prfr? Dscrib any fding problms your child xprincd during th first thr months of lif: SPEECH PATHways PAGE 9 OF 15 REVISED 04/05/07

10 Dos your child drool mor than othr childrn his/hr ag? Ys No Did your child hav difficulty gaining wight as an infant? Ys No Dos/Did your child us a pacifir? Ys No Dos/Did your child suck thir thumb? Ys No Chck any of ths as thy apply to your child: Eating problms Slping problms Toilting problms Difficulty concntrating Nds a lot of structur Intractiv Excitabl Laughs asily Cris a lot Difficult to manag Ovractiv Snsitiv Prsonality problms Gts along with othrs Emotional Stays with an activity Maks frinds asily Happy Irritabl Ys No If ys, xplain & giv ags if possibl SPEECH PATHways PAGE 10 OF 15 REVISED 04/05/07

11 PLAY BEHAVIORS Which of th following dscribs th typ of play your child liks to ngag in th most oftn? Putting toys in mouth Banging toys togthr Throwing toys Shaking toys Pushing/pulling toys Rol-playing Uss on objct for anothr Gams with ruls Rough & tumbl play Appropriat us of objcts Mak bliv play Looking at books Acting out familiar routins What is th avrag lngth of tim your child can stay playing at on activity? Which activitis sm to hold your child s attntion for th longst priod of tim? Which activitis sm to hold your child s attntion for th shortst priod of tim? Is your child s play asily distractd by any of th following? Visual stimuli (i.., othr toys or objcts) Auditory stimuli (i.., voics, sounds outsid, th TV) Narby activitis Othr popl in th room Whom dos your child prfr to play with? (Circl all that apply.) Mothr Fathr Brothr/Sistr Slf Othr Child Othr Adult List som of your child s favorit toys, TV programs and vidos: SPEECH PATHways PAGE 11 OF 15 REVISED 04/05/07

12 SOCIAL/EMOTIONAL DEVELOPMENT Chck bhaviors that you fl bst dscribs your child: Ovrly activ Ovrly quit Excssiv tantrums Dstructiv Vry shy Prfctionistic Frindly, outgoing Imaginativ and crativ Plays wll with othr childrn Prfrs oldr childrn Prfrs youngr childrn Dfiant Easily controlld/passiv Nrvous Dpndnt upon routins Difficulty sparating from parnt Thumb-sucking Drooling Tth grinding Mouth brathr Intrruptd/Unusual ating habits Intrruptd/Unusual slping habits Dscrib any disciplin problms you hav with your child: Dscrib any valuations or thrapy for bhavior or motional problms: What mthod of disciplin do you us? What mthod of disciplin dos your spous us? EDUCATIONAL HISTORY Educational Stting Child Car Facility Early Childhood Classs Birth to 3 Programs Location/School Tachr(s) SPEECH PATHways PAGE 12 OF 15 REVISED 04/05/07

13 How oftn dos your child attnd classs? Daily 4 Tims pr wk 3 Tims pr wk 2 Tims pr wk 1/2 Days Full day How many childrn ar in your child s class? What typ of classroom is your child in? (i.., traditional, opn classroom, transdisciplinary, tc.) Dos your child xhibit any larning styl prfrncs? Visual Auditory Both Dos your child s dvlopmntal prformanc sm to intrfr with his/hr school prformanc? Ys No If ys, plas xplain: Hav tachrs xprssd any concrns about your child s larning bhavior? Ys No If ys, plas dscrib: Has your child vr bn valuatd for or attndd thrapy for: Spch problms Vision problms Fding problms Haring problms Physical motor problms Othr Plas giv locations, dats, and rsults: SPEECH PATHways PAGE 13 OF 15 REVISED 04/05/07

14 What othr srvics dos your child hav now? What has h/sh had in th past? Typ of srvic Has Now Had Bfor Physical Thrapy Occupational Thrapy Spch-Languag Thrapy Psychological or Bhavioral Counsling Nutritional Srvics Othr (dscrib) HEARING HISTORY Dos your child hav a history hav a history of ar infctions or otitis mdia? Ys No How many occurrncs of ar problms? At what ag? Ag of onst? How long did ach ar problm last? What tratmnts (mdications) wr prscribd? Has your child vr bn tratd by an ar, nos, throat spcialist? Ys No Who? Whn? Dos your child say huh or what at last fiv or mor tims a day? Ys No Do you vr qustion your child s ability to har normally? Ys No If ys, plas xplain: Is your child asily distractd? Ys No Dos your child hav difficulty following dirctions? Ys No Whn was th last tim your child s haring was chckd? Within th last yar 1-3 yars ago 4 or mor yars ago SPEECH PATHways PAGE 14 OF 15 REVISED 04/05/07

15 INSURANCE INFORMATION Do you hav insuranc? Ys No If ys, provid company nam: Policy Numbr: Dos your insuranc covr spch-languag valuations? Ys No Dos your insuranc covr spch-languag thrapy? Ys No Is your insuranc a HMO? Ys No Is your insuranc a PPO? Ys No Who is rsponsibl for your child? Rlationship? Child s Doctor: Addrss: Tlphon: City: Stat: Zip: SPEECH PATHways PAGE 15 OF 15 REVISED 04/05/07