IDENTIFYING AND FAMILY INFORMATION NORTHERN ILLINOIS UNIVERSITY SPEECH-LANGUAGE-HEARING CLINIC Case History for Language-Literacy Evaluation Child s Name: _ Age: Birthdate: Sex (Circle One): Male Female Home Phone: _ Cell Phone: Work Phone: Address: City: State: Zip Code:_ Mother s Name: Father s Name: Mother s Occupation: _ Father s Occupation: Please list the name and relationship of the adult(s) who live at home with your child: Please list the names, ages, and relationships of other children who live at home with your child: Name of School: School Address: City: State: Zip: District: Who referred the child for this evaluation? Name: Speech-Language Pathologist Parent Audiologist School Counselor Pediatrician Psychologist Neurologist Classroom Teacher Otolaryngologist Reading Specialist Other Physician Teacher s Aide Other _ 1
Why was the child referred for this evaluation? Concerns about: Speech (how the child produces speech sounds) Language (how the child understands speech and how the child produces meaningful strings of words) Academic performance Reading Writing Spelling Other Describe your concerns about the child: When did you first have these concerns? What have you, your family members or others found to be particularly helpful to your child: What information would you like to know after this evaluation? Activities the child enjoys doing: Activities the child does not enjoy doing: 2
Learning style at home Mark an X next to the one style which best describes the child: The child learns best from touching and manipulating objects/models The child learns best from seeing The child learns best from listening On an average school night the amount of time your child: Reads alone Reads with the family (or is read to) Plays actively (sports or physical activities) Plays quietly Watches television/videotapes Is at a friend s house Goes to non-academic classes or lessons Studies/works on homework CHILD S CURRENT GENERAL BEHAVIOR Compared to other children the same age, rate this child s abilities/performance by marking an X in one column for each item: Better than others Similar to others Worse/Weaker than others Attention Distractibility Impulsiveness Concentration Self-Concept Motivation Social maturity Frustration level Ability to learn new things Ability to follow directions Ability to tell stories Ability to express himself/herself Ability to follow/understand stories SCHOOL What is the child s most favorite school subject? What is the child s least favorite school subject? Has anyone suggested the child repeat a grade? (Circle one) YES NO Did the child repeat a grade? (Circle one) YES NO If so, which grade? (Circle one) Kindergarten First Second Third Fourth Fifth 3
Compared to other children the same age, rate this child s abilities/performance by marking an X in one column for each item: Better than others Similar to others Worse/Weaker than others Performance in math Performance in writing Performance in handwriting Performance in spelling Attitude toward school Compatibility with classmates Compatibility with the teacher Frustration with homework Ability to follow teacher s verbal instruction Ability to follow written directions in school Ability to complete assignments In a timely fashion in school Child is enrolled in: YES NO If yes, please state the reason for receiving services Speech therapy Language therapy Remedial reading Tutoring Please list any other special services the child receives at school: Did the child s school performance worsen in the third grade when compared to earlier grades? (Circle one) YES NO N/A Did the child s attitude about school worsen in the third grade when compared to earlier grades? (Circle one) YES NO N/A How the family communicates with the child s school (circle as many as apply): Phone Letters/Notes Visits/Observations E-mail No communication 4
FAMILY HISTORY Is there someone in the immediate family who has (or had in the past): Yes No Describe Learning problems? Speech difficulties? Language difficulties? Hearing difficulties? CHILD S EARLY DEVELOPMENTAL HISTORY Describe any known or suspected problems or concerns before the child was born, or during birth: What hand does the child prefer? (Circle one) Right Left Both At what age did this preference appear? Before 2 years 2-4 years 4-6 years No preference yet Age the child began to walk?: _ talk?: MEDICAL HISTORY Indicate by marking an X for any of the following conditions that the child has currently or has had in the past: Now Previously Earaches or ear infections Hearing loss Upper respiratory infections Indicate by marking X (one or more) how upper respiratory infections and/or ear infections were treated: Medication Insertion of tubes (pressure-equalization tubes) Removal of tonsils and/or adenoids (tonsillectomy and/or adenoidectomy) Chiropractic manipulation No treatment 5
Name and describe any prescribed medications (pill, syrups, inhalers, etc.) your child is currently taking or using: Names and reasons: Names and reasons: Names and reasons: Names and reasons: Does your child s behavior change when taking these medications? (Circle One) YES NO If yes, please describe: _ Describe any known complications of childhood illnesses: Describe any serious physical injuries or hospitalizations that the child has experienced: Compared to other children the same age when this child was one to four years of age, was this child s behavior (play habits, affection, tantrums, etc.) similar to other children? (Circle one) YES NO If no, describe briefly: _ Compared to other children the same age when this child was one to four years of age, did this child learn in the same way and at the same time as other children? For example, learning to say the alphabet, learning to tie shoes, etc. (Circle One) YES NO If no, describe briefly: _ 6
OTHER EVALUATIONS: Please describe briefly any other examinations, tests, or evaluations that the child has undergone. Include when, where, and results. Evaluation for Special Education Placement: Neurologic Examination: Psychological Examination: Intelligence, Aptitude, Basic Skills Tests: Hearing Evaluation: Speech and Language Evaluation: Auditory Processing Evaluation: Vision Examination: Motor/Balance Examination: Please write anything else that you feel we should know below. THANK YOU FOR TAKING TIME TO COMPLETE THIS FORM! Please return to the NIU Speech-Language-Hearing Clinic as soon as possible so that we may adequately plan for your child s evaluation. 7