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 4 of 5

 

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** Patient Name:      
** Email Address:      
Date: 

SECTION VI – MEDICAL HISTORY

Child’s Doctor (Pediatrician): 
Doctor's Address: 
Ear, Nose and Throat Doctor: 
Neurologist: 
Psychologist: 
Other: 

Please list any illnesses, injuries or operations on the child. You may list up to three.

 

1) Type:       Age:
    Severity of Condition:      Treatment:
    Fever:      Complications:
2) Type:       Age:
    Severity of Condition:      Treatment:
    Fever:      Complications:
3) Type:       Age:
    Severity of Condition:      Treatment:
    Fever:      Complications:
If so, by whom? 
Results: 
Does he wear a hearing aid? 
If yes, for how long? 
If so, please describe: 
Have his eyes been examined? 
If yes, by whom? 
When? 
Results: 
Has he ever worn glasses? 
If not, is there any evidence of a visual problem?
Does the child have any allergies? 
List and describe treatment, 
reaction, and severity: 
About how many colds does the child have per year?
Is the child in good physical health now?
If not, describe condition: 
Current Medications: 
(name, dosage, length of time 
to be taken) 

 

 

 

 

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