Speech Language Pathologists, Nancy L. Foreman and Associates, SPEECH is the WINDOW and MIRROR of the MIND

Slow or stagnant speech development

Consistently hoarse voice

General Case History: Child - Page 1 of 5

 

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** Patient Name:      
Date: 
Address: 
Information Given By: 
Interviewer: 
Birth Date: 
Sex: 
Referred By: 
Parents' Names: 
** Email Address: 
Reports to be Sent to: 
Telephone #: 
Mother's Work #: 
Father's Work #: 

CONCERNS:

Describe the speech and/or hearing 
problems briefly: 

SECTION I – SPEECH DEVELOPMENT

At what age was a speech 
problem first noticed? 
What is the severity of this problem? 
How much of the child’s speech 
can the family understand? 
How much can other adults or 
strangers understand? 
Do parents feel the child 
stutters or stammers? 
Does the child’s voice sound like other children’s voices?
If no, describe: 
If other above, describe: 
How old was the child when he began to say words?
Putting 2 or 3 words together in a phrase such as “go bye-bye”?
Do you feel speech developed at a normal age and rate as compared to other children?
If not, describe: 
Was any foreign language taught to the child or spoken at home?
If so, what language? 
Has the child ever been evaluated by any speech or hearing specialist?
If so, who? 
Has the child had speech therapy? 
If so, where? 
When? 

 

 

 

 

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