Case History Form (Paediatrics)

The purposes of the Case History Form are to:

collect the information required to accurately assess your child’s communication and/or feeding skills, and
collect the information required to contribute to an ethical and evidence-based Treatment Plan for your child.

The information you provide is considered ‘health information’ under law. The information you provide is confidential and is stored securely, consistent with our Privacy Policy.

Please fill out this questionnaire as fully as you can. We appreciate that you have seen multiple specialists in the past who ask similar questions, and it can be repetitive to continue to provide this information. Case history is an important part of your child’s health record, and informs both our diagnosis and Treatment Plan.

The more information you provide us, the better we are able to tailor your appointment to your concerns, and provide an accurate diagnosis quickly.

Please note: you can save your progress and complete the rest of the form later using the link at the bottom of the page.

IDENTITY

We appreciate that you have already provided us with a name and date of birth. We are requesting this information again as it allows our computer system to automatically match it up to the correct file, so that we can find your information easily in the future.

Child's first name: *

Child's last name: *

Child's date of birth: *

PRENATAL AND BIRTH INFORMATION

Describe any difficulties experienced during the pregnancy, including any unusual illnesses, conditions or accidents:

At how many weeks was your child born?

Describe any issues that occurred at birth, e.g. breech birth or emergency caesarian:

Birth order: does your child have any siblings?

YesNo

Sibling's name

Age

School year

Difficulties

LanguageSpeechReading/SpellingOther

Do any other close relatives (parents, grandparents, aunts, uncles, cousins) have, or have a history of difficulties with language, speech, reading, or spelling?

POST-BIRTH INFORMATION

Child's birth weight:

Did your child have any trouble starting to breathe?

YesNo

If yes, please provide details:

Did your child have any early feeding issues? (e.g. swallowing or sucking difficulty, reflux, vomiting)

YesNo

If yes, please describe:

Was your baby breast-fed?

YesNo

Until what age?

Was your baby bottle-fed?

YesNo

Until what age?

If yes to any of the above, please provide details:

EARLY GROSS MOTOR DEVELOPMENT

At what age (approximately) did your child first:

sleep through the night regularly?

sit without support?

crawl?

walk without assistance?

feed themselves with a spoon?

At what age was your child toilet-trained?

Day:

Night:

Does your child seem clumsy or uncoordinated?

YesNo

If yes, please provide details:

LANGUAGE DEVELOPMENT

Language(s) spoken at home and with extended family members:

Main language spoken at home with primary carer:

Did your child babble regularly as a child?

YesNo

At what age did your child first:

say words?

use 2-word phrases to communicate? e.g. 'Mummy eat?', 'Me go?'

know and use 50 different words?

use sentences? e.g. 'The car is noisy.'

How does your child express his/her ideas?

Does your child seem to have trouble:

understanding and following instructions?

YesNo

understanding story sequences?

YesNo

finding the 'right words'?

YesNo

socialising with peers?

YesNo

If yes, please describe:

INTELLIGIBILITY / SPEECH DEVELOPMENT

Do strangers have difficulty understanding your child?

YesNo

Have you noticed particular sounds or words your child has difficulty with?

YesNo

If yes, what are they? Can you provide any examples?

Has your child ever spoken better than he/she does now?

YesNo

If yes, please provide details:

Has there been a change in your child’s speech in the last three months?

YesNo

If yes, please describe:

VOICE

Is your child's voice:

hoarse or strained?

YesNo

nasal?

YesNo

often too soft?

YesNo

often too loud?

YesNo

unusually high-pitched?

YesNo

unusually low-pitched?

YesNo

STUTTERING / FLUENCY

Does your child stutter, get stuck on words, repeat sounds, syllables or words, or re-start sentences?

YesNo

If yes, please provide details on when it started, how it sounds:

COMMUNICATION ISSUES

Does your child seem to be aware of his/her communication issues?

YesNo

If yes, please describe:

Has your child had a speech-language assessment or speech therapy before?

YesNo

If yes, please provide details:

If you have any speech pathology reports, please provide a copy to us so we have the background information to tailor our assessment.

Previous speech pathology letter(s) or report(s):

Browse

HEARING

Has your child had many ear infections or glue ear (otitis media)?

YesNo

If yes, how frequently?

Has your child had a hearing test (not including the newborn hearing screening)?

YesNo

If yes, when? And what were the results?

NOSE BREATHING / ADENOIDS / TONSILS / SLEEPING

Does your child appear to breathe mostly through their nose or mouth?

NoseMouth

Does your child snore?

YesNo

If yes, please provide details:

Does your child have a sleep disorder, e.g. sleep apnoea?

YesNo

If yes, please provide details:

Has your child had their adenoids or tonsils removed?

Adenoids

YesNo

If yes, when?

Tonsils

YesNo

If yes, when?

ORAL BEHAVIOURS

Did/does your child:

suck their thumb, fingers, or dummies?

YesNo

dribble?

YesNo

cough after eating or drinking?

YesNo

frequently gag on solids?

YesNo

If yes to any of the above, please provide details:

VISION

Has your child had their eyesight tested?

YesNo

If yes, when? And what were the results?

DENTAL

Has your child had their teeth checked?

YesNo

If yes, when? And what were the results?

GENERAL MEDICAL HISTORY

Has your child ever had a convulsion?

YesNo

If yes, when?

Does your child have difficulties with attention, concentration and/or memory?

YesNo

If yes, please describe:

Does your child have colds often?

YesNo

Is your child currently on medication?

YesNo

If yes, what type of medication, and for what purpose?

Does your child have any physical disabilities, challenges or impairments?

YesNo

If yes, please describe:

ILLNESSES / ACCIDENTS / SURGERIES / HOSPITALISATIONS

What illnesses, accidents, surgeries, and/or hospitalisations has your child had?

Type of illness

Age

Treatment

Were there noticeable changes in your child’s speech or communication immediately following any of these events?

YesNo

If yes, please provide details:

SCHOOL / PRESCHOOL / EARLY CHILDHOOD EDUCATION

Does your child have any issues at school/pre-school/childcare (e.g. with socialising, challenging behaviours, reading, writing or communicating)?

YesNo

If yes, please provide details:

Does your child receive special assistance or support at school/pre-school/childcare?

YesNo

If yes, please provide details:

OTHER COMMENTS

Are there any other comments that you would like to make about your child or your concerns/priorities?

PARENT / CAREGIVER CONSENT

I confirm the information I have provided in this questionnaire is true and correct, to the best of my knowledge: *

Name of parent / caregiver: *

Date: *

Signature: *

Clear

Would you like your letter of summary and recommendations to be sent to:*

your child's teacher?

YesNo

another health professional?

YesNo

Name:

*Please note: if you have been referred by your GP or are receiving a Medicare-rebate for this service, we are required to send a copy to your GP.

If you wish to receive a copy of this completed form, please provide your email address:

Save and Complete Later