Venture

Pediatric Case History Form

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Name

Phone Number

Person completing form

Person completing form

Parent Other Relationship to Child

Name

Relationship to Child

Email

Parent Concerns:
Do you have concerns regarding your child’s?

Sound production

Yes No

Understanding of language

Yes No

Production of language

Yes No

Repeating words

Yes No

Eating or Feeding

Yes No

Swallowing

Yes No

Motor Skills

Yes No

Self Help Skills

Yes No

Behavior

Yes No

Primary Language:
Does your child speak: Check all that apply:

English

Yes No

Spanish

Yes No

Do you think your child understands more when spoken to in English

Yes No

or Spanish

Or Spanish you think your child understands more when spoken to in English

Yes No

Other Language: Please specify:

Does either parent speak Spanish or a language besides English in the home?

Yes No

Past Therapy:

Has the patient had speech therapy in the past?

Yes No

If yes, Where?

School or Center: Name of School

Name of Speech Language Therapist

Currently receiving ST

Yes No

Has the patient had occupational therapy in the past?

Yes No

If yes, Where?

School or Center: Name of School

Name of Occupational Therapist

Currently receiving ST

Currently receiving OT

Yes No

Educational History:

Attends childcare or school program?

Yes No

Location

Attends after school program?

Yes No

Location

Does your child now receive early intervention services from CDSA?

Yes No

Milestones Checklist:

Current communication

Does your child speak

Did the child speak their first word between 12-14 months?

Yes No

Did the child put words together by 24 months?

Yes No

Does your child make sentences?

Yes No

Does your child follow directions?

Yes No

Does your child like play with toys?

Does your child like play with toys

Yes No

Would your child rather play alone or with other children?

Would your child rather play alone or with other children

Alone Other

Did the child walk between 10-14 months?

Yes No

Did your child sit up at 6 months?

Yes No

Did your child walk at 14 months?

Yes No

Does the child have any problem eating any foods?

Yes No

Does the child gag, cough or choke when eating or drinking?

Does the child have any problem eating any foods?

Yes No

Has the child had any difficulty gaining weight?

Yes No

Does your child such his/her thumb?

Yes No

Does your child use a pacifier?

Yes No

Does your child have a lisp?

Yes No

Is your child a mouth breather?

Yes No

General Behaviors:
Does your child exhibit any of the following?

Clumsiness

Yes No

Difficulty walking or running?

Yes No

Difficulty buttoning or zipping?

Yes No

Tantrums

Yes No

Head banging

Yes No

Make repetitive motions

Yes No

Respond when his/her name is called?

Yes No

Inattentive

Yes No

Makes eye contact

Yes No

Birth History:

Was the child born full term?

Yes No

Gestional weeks at birth

Did the child come home from the hospital when you came home?

Yes No

Any Complications at birth?

Yes No

Birth Weight

Pounds

Ounces

If any complication, Describe

Hearing History:

Has your child had a recent hearing screening test

Yes No

Did they pass or fail the test?

Yes No

Do you think that your child can hear you?

Yes No

Do you have any concerns regarding hearing?

Yes No

Has the child had frequent ear infections?

Yes No

Has the child had PE tubes placed in the ears?

Yes No

Has your child been diagnosed with a hearing loss:

Yes No

If yes: By Whom

Has your child been diagnosed with a hearing loss:

Type of Loss:

Conductive Sensorineural Unknown

Does your child have a hearing aid?

Yes No

If yes, is the hearing aid in one ear

is the hearing aid in one ear

Left Right Both

If yes, do both hearing aids work?

Yes No

If yes, do you have both hearing aids in workable condition at home?

Yes No

Does your child have a cochlear implant?

Yes No

Has anyone in the family had speech therapy, autism, etc.?

Yes No

Medical History:
Has your child been diagnosed with?

ADD/ADHD

Yes No

If yes, by whom?

Autism

Yes No

If yes, by whom?

Learning Disability

Yes No

If yes, by whom?

Developmental Delay

Yes No

If yes, by whom?

Trauma at Birth?

Yes No

If yes, by whom?

Allergies

Yes No

Asthma

Yes No

Heart Disease

Yes No

Cerebral Palsy

Yes No

Cleft palate

Yes No

Cleft Lip

Yes No

Down Syndrome

Yes No

Fetal Alcohol Syndrome

Yes No

Fragyle

Yes No

Feeding Issues

Yes No

Difficulty Swallowing

Yes No

Gastric Reflux

Yes No

Traumatic Brain Injury

Yes No

Seizure Disorder

Yes No

Epilepsy

Yes No

Tongue Tie

Yes No

Lip Tie

Yes No

Visual Impairment

Yes No

Physical Abuse/Neglect/Trauma

Yes No

Psychological Trauma

Yes No

Childhood Emotional Disorder/Childhood Trauma

Yes No

Tourette's Syndrome

Yes No

Post-COVID complication

Yes No

Has anyone told you they are concerned about your child having autism?

Yes No

Has anyone in the family had autism, etc.?

Yes No

Has anyone in the family had speech therapy, autism, etc.?

Yes No