Pediatric Case History Form

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Person completing form
Parent Concerns:
Do you have concerns regarding your child’s?
Sound production
Understanding of language
Production of language
Repeating words
Eating or Feeding
Motor Skills
Self Help Skills
Primary Language:
Does your child speak: Check all that apply:
Do you think your child understands more when spoken to in English
or Spanish
Does either parent speak Spanish or a language besides English in the home?
Past Therapy:
Has the patient had speech therapy in the past?
Currently receiving ST
Has the patient had occupational therapy in the past?
Currently receiving ST
Educational History:
Attends childcare or school program?
Attends after school program?
Does your child now receive early intervention services from CDSA?

Milestones Checklist:
Current communication
Does your child speak
Did the child speak their first word between 12-14 months?
Did the child put words together by 24 months?
Does your child make sentences?
Does your child follow directions?
Does your child like play with toys?
Would your child rather play alone or with other children?
Did the child walk between 10-14 months?
Did your child sit up at 6 months?
Did your child walk at 14 months?
Does the child have any problem eating any foods?
Does the child gag, cough or choke when eating or drinking?
Has the child had any difficulty gaining weight?
Does your child such his/her thumb?
Does your child use a pacifier?
Does your child have a lisp?
Is your child a mouth breather?

General Behaviors:
Does your child exhibit any of the following?
Difficulty walking or running?
Difficulty buttoning or zipping?
Head banging
Make repetitive motions
Respond when his/her name is called?
Makes eye contact

Birth History:
Was the child born full term?
Did the child come home from the hospital when you came home?
Any Complications at birth?

Hearing History:
Has your child had a recent hearing screening test
Did they pass or fail the test?
Do you think that your child can hear you?
Do you have any concerns regarding hearing?
Has the child had frequent ear infections?
Has the child had PE tubes placed in the ears?
Has your child been diagnosed with a hearing loss:
Has your child been diagnosed with a hearing loss:
Does your child have a hearing aid?
If yes, is the hearing aid in one ear
If yes, do both hearing aids work?
If yes, do you have both hearing aids in workable condition at home?
Does your child have a cochlear implant?
Has anyone in the family had speech therapy, autism, etc.?

Medical History:
Has your child been diagnosed with?
Learning Disability
Developmental Delay
Trauma at Birth?
Heart Disease
Cerebral Palsy
Cleft palate
Cleft Lip
Down Syndrome
Fetal Alcohol Syndrome
Feeding Issues
Difficulty Swallowing
Gastric Reflux
Traumatic Brain Injury
Seizure Disorder
Tongue Tie
Lip Tie
Visual Impairment
Physical Abuse/Neglect/Trauma
Psychological Trauma
Childhood Emotional Disorder/Childhood Trauma
Tourette's Syndrome
Post-COVID complication
Has anyone told you they are concerned about your child having autism?
Has anyone in the family had autism, etc.?
Has anyone in the family had speech therapy, autism, etc.?