COLLEGE OF ARTS & SCIENCES Department of Communication Sciences and Disorders Speech-Language-Hearing Clinic 3750 Lindell Blvd., Suite 32 St. Louis, MO 63108 Ph 314-977-3365 F 314-977-1615 ADOLESCENT FLUENCY CASE HISTORY Today s Date: Name: Date of Birth: Address: City State Zip Code Email Address: Phone-H Phone-C Gender: Male Female Parent(s) or Guardian(s): Child lives with both parents? Yes: No Primary language spoken in home? Pediatrician: Phone: Referred by: Previous Evaluations (list): Therapy to date (list): Describe Present Problem: Parent Occupation: Level of Education: Parent Occupation: Level of Education: Other People in the Household: Name: Age: Relationship: Name: Age: Relationship: Name: Age: Relationship: Name: Age: Relationship: 1
STATEMENT OF PROBLEM (for parent or guardian to complete) Describe in your own words your child s speech: When was the problem with his/her speech first noticed? By whom? What did the stuttering sound like when it first began? Has the problem changed since that time? If yes, explain. Describe how your child s speech sounds now: Do you have difficulty understanding your child? How well is your child understood by: (what percentage of the time?) Mom: Dad: Younger Siblings: Older Siblings: Other Children: Extended Family: Unfamiliar Adults: What do you do when he/she stutters? When is his/her stuttering most noticeable? Has your child ever been teased about stuttering? Describe or give examples: Does your child use the word stutter when referring to himself or his speech? Does your child comment on his/her speech or in any way let you know he/she is concerned? If so, explain: Do you feel his/her speech has gotten better or worse lately? Does anything help your child when he/she is stuttering? If yes, provide example(s): Has your child ever demonstrated any: (answer yes or no) 2
Awareness of stuttering Frustration about speaking Describe or give examples: Physical tension during stuttering Complaints that he/she Can t talk Is there any history of stuttering in the family (including extended family)? If so, explain (immediate family, mother s side, father s side): Does your child s stuttering affect his/her (if yes, explain): Interaction with family members? Interaction with peers? Willingness to talk and communicate? Self-esteem or attitude toward self? Academic Performance? Participation in school activities? If you were to indicate what factors you think may be related to your child s stuttering, which ones would you include? Circle as many as you think are possible and/or list others: Behavior problems Inconsistency of parent handling Neglect by father Overprotection by mother Emotional Insecurity Neglect by mother Sensitivity Environmental problems Lack of playmates Nervousness Sibling rivalry Feelings of insecurity Marital/family problems Overprotection by father Strong dislikes Other (list): Do you notice that your child tends to stutter more when he/she is (check all that apply): Yes No a. Very happy or pleased b. Angry c. Tired d. Excited e. Talking to teachers f. Talking to pets g. Talking before a group h. Talking to good friends i. Talking to parents j. Asking permission k. Talking on the telephone l. Talking to strangers EARLY SPEECH AND LANGUAGE HISTORY As an infant, did he/she babble and coo during first 6 months? When did he/she speak his first word? Sentences? 3
Did he/she use speech frequently? Occasionally? Never? Did he/she prefer to use speech or gestures? (Give examples) Did he/she prefer to use: Complete sentences? Phrases? One or two words? GENERAL DEVELOPMENT Indicate ages at which child accomplished the following: Sat alone: Stood alone: Crawled: Walked alone: Bladder trained: Waking: Sleeping: Bowel trained: Waking: Sleeping: Dressed self satisfactorily: Was child s rate of growth seemingly normal? Was normal development interrupted by anything? MEDICAL HISTORY Please check if your child has had any of the following (and if so, at what age): Age Age Age Age Asthma Encephalitis Meningitis Sinusitis Chicken Pox Enlarged Glands Mumps Thyroid Chronic Colds Heart Trouble Pneumonia Tonsillitis Croup High Fever Rheumatic Fever Tuberculosis Diphtheria Measles Seizures Whooping Cough Explain any checked items here: Are immunizations current? Current general health: Has your child had any earaches/ear infections? Yes No Please explain: Allergies? (Describe) Any other serious or recurrent illnesses? (Describe) Any operations? (Describe) Any accidents? Any medications? (Past): (Current): Vision problems? Hearing difficulties? Dental problems? Other medical history? Treatment: Treatment: Treatment: 4
DAILY BEHAVIOR Does he/she sleep well? Does he/she eat well? What are your child s hobbies/interests? How does he/she occupy/amuse himself/herself when alone? Does he/she prefer to spend time alone or with peers? Ages of friends?: How does he/she get along with peers? How does he/she get along with adults? Is it difficult to discipline him/her? Would you describe him/her as basically happy or unhappy? What other information can you supply that will enable us to better know and understand your adolescent (e.g., hobbies, interests, social skills, triggers)? Please describe your specific concerns regarding his/her fluency and the goals that you hope to accomplish through therapy (can write on back if needed): Parent Signature Date Printed Name 5
PLEASE GIVE PAGES 6-8 OF THE FORM TO THE ADOLESCENT TO FILL OUT Please place a mark beside the following situations where you feel confident speaking: At home At school In class Social occasions Ordering in restaurants Social phone calls with family or friends Asking for information from an unfamiliar person (i.e., for directions) Speaking with persons of authority (boss, teacher, etc.) Speaking with familiar persons Please explain further why you feel less confident speaking in the situations you did not mark: List any additional situations in which you feel less confident speaking: List any additional situations in which you feel more confident speaking: Does your stuttering affect your (if yes, explain): Interaction with family members? Interaction friends and peers? Willingness to talk and communicate? Self-esteem or attitude toward self? Academic performance? How would you rate your speech fluency for the following areas? Excellent Good Fair Poor Reading Out Loud: Speaking: Do other people have difficulty understanding you? Relatives? Strangers? Friends? When did you first notice your stuttering? What were you doing?: Did the first blocks seem to be located in the (check all that apply): Tongue Diaphragm (around your lungs) Lips Throat Chest Unknown About how long did each block (on one word) seem to last? 6
Was the stuttering easy or was there force at the time when the stuttering was first noticed? Were the words that were stuttered at the beginning of sentences, or were they scattered throughout the sentence being said? Do you ever avoid speaking because of the stuttering? Give examples, if any: At the time stuttering was first noticed, what was your reaction: Noticed that speech was different? Anger or frustration? Shame? Indifference/Didn t really care? Fear of stuttering again Surprise? Other: PLEASE REFLECT ON YOUR SCHOOL GRADE PERFORMANCE (For each subject, check the box that is appropriate) Above Below SUBJECT Excellent Average Average Average Poor READING SPELLING MATH SCIENCE SOCIAL STUDIES LANGUAGE ARTS PHYSICAL EDUCATION Do you receive any special education services? Yes If yes, please describe: No Name of school you attend: Names of other schools attended from K-12 including grades you were as a student: Grade Level: Were any grades repeated? Explain: Do you participate in extracurriculars? If yes, please list: How is school social life? 7
DURING SCHOOL DO YOU... Always Often Seldom Never Display self-confidence? Comply with family rules? Comply with school rules? Converse freely with others? Show respect for your property? Perform tasks/chores when asked only once or twice? Become upset easily? Have temper tantrums? Explain anger without being asked? Have difficulty concentrating? Have difficulty understanding spoken directions? Have difficulty understanding written directions? ARE YOU.. Always Often Seldom Never Able to work in a group. Difficult to discipline. Mildly active. Affectionate. Quiet. Easily distracted/have a short attention span. Easily frustrated; gave up easily. Overactive; couldn t sit still ADDITIONAL INFORMATION Please describe your specific concerns regarding your speech, language, or hearing and the goals that you hope to accomplish through therapy (can write on back if needed): Adolescent s Signature Date Printed Name Paul C. Reinert S.J., Clinics for Family and Child Development Speech-Language-Hearing Clinic Early Childhood Learning Center Center for Counseling and Family Therapy Special Learning Clinic Adolescent Fluency Case History.docx 021412 8