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 5 of 5 (final)

 

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SECTION VII – FAMILY

Are the parents now separated? 
Divorced? 
If so, how old was the child when this occurred? 
Who has custody? 
Is the child adopted? 
If yes, how old was he when he was adopted? 
Father’s Occupation: 
Father's Place of Employment: 
Father's Level of Education: 
Mother’s Occupation: 
Mother's Place of Employment: 
Mother's Level of Education: 
If mother works, who takes care of the child?
How old was the child when the mother went to work?
1) Name     Age     Grade in School
2) Name     Age     Grade in School
3) Name     Age     Grade in School
4) Name     Age     Grade in School
Are there others living in the home besides parents and children? 
Cleft Lip and/or Palate? 
Trouble Speaking or who 
had been Late to Talk? 
Trouble Hearing or Deafness? 
Trouble Learning in School? 
Failed 2 or More Grades? 
Dropped out of School due to Failure? 
Problems Learning to Read? 
Mental Retardation? 
Epilepsy? 
Cerebral Palsy? 
Other? 
If other, explain: 

 

 

 

 

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