Reading Clinic Case History Form-Pediatric

 

University of Florida Speech & Hearing Clinic                                                    File No: ____

435 Dauer Hall

Gainesville, FL. 32611-7420

(352) 392-2041

 

 

                                           General Background Information

 

 

Date: ____________________________ Client’s Name:_______________________________________

 

Birth date: ________________________ □ Male   □ Female

 

Social Security#: ______________________________________________________________________

 

Parent’s name(s) ______________________________________________________________________

 

Home phone#:    ________________________ Work phone#: _________________________________

 

Address: _____________________________________________________________________________

_____________________________________________________________________________________

 

Do you have Medicaid?            □ Yes □ No

 

If yes, please provide your policy card #: ________________________________________(8 digits)

 

Name of primary care/family physician: ____________________________________________________

 

Telephone # of primary care/family physician: _______________________________________________

 

Please describe the problem that brings you here: _____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Who referred you to this clinic? ___________________________________________________________

 

Has there been a diagnosis of a reading, Language or learning problem?    □Yes       □No

 

If yes, what type of problem and when was it diagnosed: _______________________________________

_____________________________________________________________________________________

 

Has treatment been received? □Yes       □No

 

If yes, what type? ______________________________________________________________________

_____________________________________________________________________________________

Which of the following professional services have been received? (check those that apply)

 

□ Physical therapy                     where____________when_____________why________________

 

□ Occupational therapy              where____________when_____________why________________

 

□ Speech/Language therapy       where____________when_____________why________________

 

□ Behavioral therapy                 where____________when_____________why________________

 

□Psychological counseling          where____________when_____________why________________

 

Have academic tutoring been sought?  □Yes   □ No

 

If yes, in what area(s): _______________________________________________________________

_________________________________________________________________________________

where__________________________________when______________________________________

 

When were you first concerned about reading, language or learning problem?

__________________________________________________________________________________

__________________________________________________________________________________

 

What reasons do you feel may help explain these readings or other academic difficulties?

____________________________________________________________________________________

____________________________________________________________________________________

 

 

 

                                                      Developmental History

 

Client was the (1st, 2nd, etc…) ____________ born of (number of) ________________ Children.

 

Client’s weight at birth: ____________

 

Where there and problems during pregnancy? □ Yes     □ No

 

If yes, describe _______________________________________________________________________

____________________________________________________________________________________

 

Where any medications taken during the pregnancy? □ Yes      □ No

 

List: ________________________________________________________________________________

 

Explain any difficulties at time of birth: ____________________________________________________

____________________________________________________________________________________

If premature birth, please note length of term: ________________________________________________

 

Was there a prolonged hospital stay? □ Yes       □ No

 

Why? _______________________________________________________________________________

 

When did child: Sit alone? ___________  Button clothes? _____________   Stand alone?____________

 

                        Tie shoes? ___________ Walk alone? _________________ Feed self? ______________

 

                        Become toilet trained? ___________

 

Does your child ever have trouble nursing, drinking or eating (for example, choking and/or gagging)?

□ Yes    □ No

 

If yes, explain:   _______________________________________________________________________

_____________________________________________________________________________________

 

Handedness for writing:       □ Right                   □ Left               □ Both

 

Coordination:                       □ Good                   □ Average        □ Clumsy

 

Activity level:                      □ Unusually active   □ Very active    □ Average        □Poor

 

 

 

                                                        Medical History

 

 

General Health conditions:          □ Excellent       □ Average        □ Poor

 

Any serious illness? □ Yes         □ No    If yes, explain _______________________________________

_____________________________________________________________________________________

 

Any operations?       □ Yes        □ No    If yes, explain _______________________________________

_____________________________________________________________________________________

 

 

Any injuries?         □ Yes           □ No    If yes, explain _______________________________________

_____________________________________________________________________________________  

 

 

 

 

 

 

 

 

 

Please check all that apply and provide clarifying information under “Comment”:

 

ILLNESS                                                                                                 COMMENT

Y

N

Allergies

 

 

Recurrent colds/flu sore throat

 

 

Dizziness

 

 

Dental problems

 

 

Frequent laryngitis / hoarseness

 

 

Epilepsy/seizure disorder

 

 

Reading and/or spelling problems

 

 

Other academic problems

 

 

Attention Deficit Disorder (ADD)

 

 

ADD with Hyperactivity

 

 

Vision problems

 

 

High fevers

 

 

Kidney problems

 

 

Swallowing/digestive disorders

 

 

Respiratory difficulties

 

 

Heart/circulatory problems

 

 

Neurological disorders

 

 

Cancer

 

 

Endocrine/metabolic disorders

(thyroid problems, diabetes)

 

 

Viruses (HIV, Herpes)

 

 

Connective Tissue Disorders

(Lupus, Rheumatoid Arthritis)

 

 

Frequent and/or intense headaches

 

 

Measles

 

 

Mumps

 

 

Chicken Pox

 

 

Meningitis

 

 

Unusual fatigue/stress

 

 

Mental illness

 

 

Congenital disorders (list please)

 

 

 

Additional Comments: __________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

AUDIOLOGIC HISTORY

 

Please check the appropriate column:

                                                                                                                                                             Y     N

My child had 3+ ear infections between birth and 12 months of age.

 

 

My child has had at least one ear infection which lasted more than 3 months.

 

 

My child has been evaluated by an audiologist who determined that

his/her hearing is within normal limits. Date of visit:

 

 

My child has failed a hearing screening in school. Date of screening: _______

 

 

My child has passed a hearing screeing in school. Date of screening: ________

 

 

I suspect my child has a hearing problem.

 

 

My child prefers one ear over the other. If yes, which ear? □ R □ L

 

 

My child has had tubes in his/her ears. If yes, when? _______________

 

 

My child wears hearing aids. If yes, what type and for how long?

 

 

 

 

 

 

 

Comments: ___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

 

SPEECH AND LANGUAGE DEVELOPMENT

 

 

At what age did your child:

 

Begin babbling? ________                                       Use first words? ___________

 

Begin to combine words? ____________    Begin to use sentences? ____________

 

 

Please check the appropriate box:

 

Yes

No

Did the sounds in your child’s speech ever interfere with his/her ability to be understood

by you or others?

 

 

Does your child have problems being understood now?

 

 

Does your child ever act like he/she is deaf and cannot understand what you say?

 

 

Does your child often fail to give close attention to details or makes careless mistakes in school work or other activities?

 

 

Does your child have difficulty organizing tasks and activities?

 

 

 

 

Does your child often not seem to listen to what is being said to him or her?

 

 

Does your child often not follow through on instructions and fail to finish schoolwork, chores, or duties in the workplace (due not to oppositional behavior or failure to understand instructions).

 

 

Does your child often not follow through on instructions and fail to finish schoolwork, chores, or duties in the workplace (due not to oppositional behavior or failure to understand instructions).

 

 

Does your child often have difficulty sustain attention in tasks or play activities?

 

 

Does your child often avoid or strongly dislike tasks (such as schoolwork or homework) that require a sustained mental effort?

 

 

Does your child often lose things necessary for tasks or activities (e.g., school assignments, pencils, books, tools, or toys)?

 

 

Is your child often easily distracted by extraneous stimuli?

 

 

Is your child often forgetful in daily activities?

 

 

Does your child often fidget with hands and feet or squirm in seat?

 

 

Does your child often leave his/her seat in the classroom or in other situations in which remaining seated is expected?

 

 

Does your child often have difficulty in playing or engaging in leisure activities quietly?

 

 

Does your child often blurt out answers to questions before the questions have been completed?

 

 

Does your child often have difficulty waiting in lines or awaiting a turn in games or group situations?

 

 

Does your child ever seem confused when you give instructions and/or show difficulty in

understanding what you say?

 

 

Does your child ever have trouble producing complete sentences that you think he/she should be able to produce?

 

 

Does your child ever engage is excessive repetition of words or sentences that he/she heard other people say?

 

 

Does your child ever have difficulty recalling a familiar word while he/she is speaking?

 

 

Did your child ever repeat TV commercials or radio show ads in a rote way that seemed strange to you (like he or she was reading a script)?

 

 

Does your child have problems in learning to read or spell now?

 

 

Does your child have problems in learning that certain letters correspond with certain sounds?

Does your child have problems in learning the alphabet?

 

 

 

Does your child ever sound like he/she is stuttering or hesitancy with his/her speech?

 

 

 

 

Comments: ___________________________________________________________________________

_____________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

 

 

 

 


 

FAMILY HISTORY

 

 

 

Mother  _______________Age______ Highest grade in school_______ Occupation_________________

 

Father: ________________Age_______ Highest grade in school_______ Occupation________________

 

Children: ______________ Age_______Highest grade in school_______Occupation­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_________________

  

   ______________ Age_______Highest grade in school_______Occupation_________________

 

   ______________ Age_______Highest grade in school_______Occupation_________________