INTAKE CASE HISTORY FORM

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INTAKE CASE HISTORY FORM I. Identifying Information Today s Date: Student s Name: Last First Middle Date of Birth: / / Gender: Male / Female Has there been a change in address, since the student s application for admission to MSD? Yes / No If yes, please include new address Student s Social Security Number: / / Since what date has the student lived in MD? II. Developmental History A. Pre/Post Birth: Prenatal complications - please identify any factors that may have affected the child during pregnancy (i.e., bleeding; medications; injury; sickness; in-utero substance exposure; etc.): Length of pregnancy: Full term/premature How many weeks? Birth weight: Birth height: Health of child at birth: Hospital where child was born: Postnatal complications (jaundice; breathing problems; NICU stay; extended hospital stay; artificial ventilator), if any: B. Developmental Milestones (when did your child....?): Crawl Stand alone Walk alone Begin babbling/talking Begin using sign language Accomplish toilet-training Any parental concerns regarding your child s development?

2 III. Medical History Name and address of pediatrician: Is your child currently taking any prescription medications? Yes / No If yes, please list: Has your child ever had surgeries or been hospitalized? Yes / No If yes, please list all along with the doctor s name that treated the condition: Does your child have any restrictions to physical activities, sports, or swimming? Yes / No If yes, please explain: Does your child wear eyeglasses and/or contact lenses? Yes / No Date of child s last vision exam? Date of child s last dental exam? Is there a family history of medical or emotional/behavioral concerns? Yes / No If yes, please explain: Motor Coordination: Handedness: Right / Left Can your child: Button - Yes / No Snap - Yes / No Zip - Yes / No Dress independently - Yes / No Tie own shoes - Yes / No Eat independently - Yes / No Participate in Sports - Yes / No Please describe any restrictions or limitations: Nutrition: Does your child have a medical condition that requires a special diet? Yes / No If yes, please explain: List any food allergies/ food intolerance or ethnic/religious food restrictions: Has your child ever been evaluated for feeding/swallowing? Yes / No If yes, please explain:

Does your child currently receive any of the following services? Service Yes No Where / Who? How Often?? Speech-Language therapy Aural (re)habilitation/ Auditory Training PT (Physical Therapy) OT (Occupational Therapy) Educational Tutoring Counseling Services Behavior Support (FBA, BIP) Other 3 Please indicate if your child has experienced any of these conditions: Illness or Medical Concern Yes / No Age of Onset / Diagnosis Attention deficit disorder (ADHD) Allergies Anemia Anxiety Asthma Chicken pox Colic (as a baby) Concussion Depression Diabetes Ear infections Encephalitis Fainting or Dizziness Head injury Heart problems High fevers Measles Mumps Menses Meningitis Migraines / headaches Pneumonia Seizures Serious injuries Skin Conditions Strep Infection Ushers Syndrome / Retinitis Pigmentosa Whooping Cough Other: Other: Explain (Use back of paper, if necessary)

IV. Hearing Status 4 Child s age when hearing loss was first suspected: Child s age when hearing loss was confirmed by professional? Name of center/agency where test was completed: Cause of child s hearing loss: Is there a history of hearing levels changing? Yes / No If yes, please explain: Is anyone in the family or extended family Deaf or Hard of Hearing? Yes / No (If yes, please list) Describe child s hearing levels: Right ear Left ear Date of most recent audiological exam: Audiologist: Name of center/agency where test was completed: Does your child own a hearing aid? Yes / No (If Yes, please fill out questions below) If yes, Right Ear (Make/Model) Left Ear (Make/Model) At what age did your child begin using hearing aids? Does your child currently use hearing aids at: Home - Yes / No School - Yes / No Does your child have a cochlear implant (CI)? Yes / No (if Yes, please fill out questions below) If yes, CI for Right Ear? Yes / No CI for Left Ear? Yes / No CI manufacturer: Advanced Bionics Med El Cochlear Please list date of surgery and hospital: Where does your child currently receive CI mapping services: Does your child wear the CI consistently? Yes / No (If no, explain when the CI is used) Were there any complications during the CI surgery? Yes / No (If yes, please explain) V. Communication How do you and your child communicate at home? (Check all that apply) ASL Sign and speech together at the same time Cued Speech Oral/Aural Gestures Finger spelling Signed English (PSE, SEE) Homemade signs Other (describe) How successful is your child s communication at home?

5 What is your child s preferred method of communication in the classroom? ASL Sign and speech together at the same time Cued Speech Oral/Aural Other (describe) How successful is your child s communication at school? Is your child s speech easily understood by family members? Yes / No Can people unfamiliar with your child understand his/her speech? Yes / No What do you feel is your child s best mode of communication? What are your concerns, if any, do you have about your child s communication skills? VI. Educational History A. Parent-Infant Program/Early Intervention Services/Family Education: B. Elementary: C. Middle: D. High School:

VII. Miscellaneous 6 What characteristics (i.e., happy, sad, shy, active, etc.) best describe your child? What are your child s learning strengths? What are your child s favorite hobbies or activities? What concerns, if any, do you have for your child s learning? What concerns, if any, do you have regarding your child s behavior and/or social-emotional development? Name of person(s) completing this case history: Signature(s): Relationship to Student:

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