Sumaya Babamia Speech Therapy Client Case History Form

Please take time to fill out as much information as possible regarding your

child’s developmental history to date. I understand that these forms can be time consuming. However, it is very important that I have as much information as possible to provide the best possible service for your child. Try to be as accurate as possible, but do not worry if you cannot recall details, or if certain categories are not applicable to your child.

If your child has any recent evaluations completed by other health professionals(psychologist, occupational therapist, play therapist, teacher/school, medical practitioner etc.), please email copies to [email protected]. Alternatively, please bring copies of these with you at your child’s next therapy appointment.

Child's Name *

First

Middle

Last

Child's Date of Birth

Primary parent/legal guardian: *

First

Last

Primary parent/legal guardian: Address *

Primary parent/legal guardian: Home Phone Number *

Primary parent/legal guardian: Mobile Number *

Primary parent/legal guardian: ID Number *

Secondary parent/legal guardian: *

First

Last

Place of residence if different to the primary parent/legal guardian):

Physical address of the child’s place of residence : *

Emergency contact (name, relationship, phone): *

Emergency contact (name, relationship, phone #)

Has your child received other evaluations or treatment? *

If Yes please describe

Evaluation Date :: .... Professionals Name :: .... Dates of Therapy :: ....

Please tell me about your child. Do include interests, hobbies, and any other information you think to be relevant. *

Would you Describe your child as Quite? *

Yes
No
At Times

Would you Describe your child as Overly Active? *

Yes
No
At Times

Would you Describe your child as Impulsive? *

Yes
No
At Times

Would you Describe your child as Restless? *

Yes
No
At Times

Would you Describe your child as Stubborn? *

Yes
No
At Times

Does your child tire easily? *

Yes
No
At Times

Does your child talk constantly? *

Yes
No
At Times

Does your child over react? *

Yes
No
At Times

Does your fight frequently? *

Yes
No
At Times

Would you Describe your child as Happy? *

Yes
No
At Times

Does your child have frequent temper tantrums? *

Yes
No
At Times

Would you Describe your child as Clumsy? *

Yes
No
At Times

Would you Describe your child as Clumsy? (copy) *

Yes
No
At Times

Does your child have a poor attention span? *

Yes
No
At Times

Does your child get frustrated easily? *

Yes
No
At Times

Does your child have poor self esteem? *

Yes
No
At Times

Does your child rock them self to calm down? *

Yes
No
At Times

Does your child have nervous ticks or habits? *

Yes
No
At Times

If yes please describe them

Does your child have unusual fears? *

Yes
No
At Times

If yes please describe them

Please summarise your concerns about your child’s speech-language profile *

Describe what it’s like to have a conversation with your child. *

Do you have other concerns about your child’s development? *

Has your child had reactions to the concerns which you have described above (e.g. is your child aware of his or her difficulties?) *

Does your child’s reaction concern you or significant family members? Please explain. *

Please list all the people who live at home with the child. Include siblings, parents, grandparents, nanny, helper, and significant others. You are encouraged to comment on the relations with the child if you think it necessary. *

Describe your child’s social and interpersonal skills. Where relevant, please include friendships with peers, adults (teachers), significant others, animals, as well as religious/sports/extra-curricular activities. *

Please list your child's regular playmates *

Names :... Ages: .... Genders:....

Activities shared with parents and siblings: *

How does your child handle frustration? *

How does your child handle conflict? *

How does your child handle separation? *

How does your child handle Regular responsibilities (e.g. assisting with household chores, looking after personal possessions)? *

How does your child handle Favourite places? Unfamiliar places? *

How does your child handle Strange / new people? *

How many minutes/hours of television does your child watch per day? *

How many minutes/hours of electronics does your child have per day? *

What motivates your child most? *

What discipline methods work best? *

Please describe any significant family history with speech *

Please describe any significant family history with hearing *

Please describe any significant family history with feeding *

Please describe any significant family history with learning *

Please describe any significant family history with emotional difficulties *

Please describe any significant family history with physical difficulties *

What is your child’s current state of health? *

Medical diagnosis (if any):

Explain any of the items ticked above here: *

Please include the age your child was for each

Are immunizations up to date? *

Has your child had any earaches/ear infections? *

Yes
No
Grommets

If chronic, please explain frequency here:

Allergies? If yes, please describe.

Any other serious or recurrent illnesses?

Any operations? If yes, please describe.

Any accidents/falls involving trauma to the head?

Any medications? If Yes, please list along with dosage and # per day

Has your child had any Vision problems? *

If yes, please explain the nature of the problem.

Date of last eye test *

Has your child had any Hearing Difficulties *

If yes, please explain the nature of the problem.

Date of last hearing test *

Has your child had any Dental problems *

If yes, please explain the nature of the problem

Any structural injuries or functional difficulties relating to the head, neck, throat, oral and nasal cavities?

If yes, please explain in more detail.

Are there any medical precautions the therapist should be aware of when working with your child? If yes, please explain *

Did the mother have infections/illnesses during pregnancy? *

If yes, please describe:

Did the mother have any shocks or unusual stresses during pregnancy? *

If yes, please describe:

Did the mother receive any medication during pregnancy? *

If yes, please describe:

Did the mother have any complications/difficulties during delivery/labor? *

If yes, please describe:

Was your child full term? *

What was their birth weight? *

Was your child born premature? *

If yes what was the number of weeks

Require a C-Section for delivery? *

Yes
No
Scheduled
Emergency

If yes please indicate if it was scheduled or an emergency

Thank you for taking the time to fill out your child’d developmental history please click here to complete the practice terms and conditions.