Pediatric Case History Form (American English version)
This 4-page Case History Form (with 2 additional pages of interpretation guidelines), is intended for ages 3 and up.
- Collect all pertinent background information about family history, birth history, medical history, feeding/eating history, developmental history, educational/academic history, speech/language history.
- Gather relevant information to aid in the differential diagnosis of speech and language disorders.
- Uncover possible red flags for childhood apraxia of speech, dysarthria, myofunctional disorders, noxious oral habits, relevant medical conditions, learning disabilities, language disorders, feeding disorders, genetic conditions, developmental delays, and sensory processing deficits.
- Questions are purposefully redundant, helping parents and caregivers provide thorough histories.
- 2 additional pages of guidelines with references to help SLPs determine when to make appropriate referrals and/or when to consider additional assessments.
IMPORTANT: This form is downloadable only ONCE per quantity selected, please make sure you download it to a computer, not your phone. If purchasing for multiple clinicians, select the quantity corresponding to the number of clinicians in your group. A downloadable PDF will be sent to the email provided. Once downloaded, save to your computer immediately.
**Clinicians: This form may only be printed for your own use. You may not copy, share, reproduce, post or display in any manner.***