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UNIVERISTY OF ARKANSAS-FAYETTEVILLE
SPEECH AND HEARING CLINIC

SPEECH/LANGUAGE/HEARING Case History/ CHILD

TO THE PARENTS OR GUARDIAN:

You have requested an appointment for an evaluation of your childs speech, language, hearing problem. To plan ahead for
this interview, we need certain information. Please complete this form to the best of your ability.
All information will be held confidential.
I.

General Information
Childs Name: Abigail Smith
Birth Date:
Address:

08/17/10

Phone: 479-555-8293

Age:

4:7

1111 Grad School Blvd.

School:

Sex:

City:

Little Wonders Preschool

Grade: Preschool

Fayetteville

State: AR

Zip: 72701

Teacher: Miss Daisy

School District:________________________________________________________________________________
Fathers Name:
Address:

Torry Smith

1111 Grad School Blvd.

Occupation:

Age: 23_
City:

Certified Public Accountant

Place of Occupation:

Fayetteville

State: AR

Zip: 72701

Business Phone: 479-555-6321

ABF Freight System, Inc.___________________________

Education; number of years completed: Bachelors in Accounting; 4 years__

Mothers Name:
Address:
Occupation:

Kerri Smith
Same as above
Stay at home mom

Place of Occupation:

Age: 23_
City:

State:

Zip:

___

Business Phone: 479-555-0107

Not applicable__________________________________________

Education; number of years completed:

Bachelors in Elementary Education; 4 years

If mother is employed, who cares for the child?_____N/A______________________________________

Who will be responsible for payment of charges?

Insurance/ Parents________________________

Brothers and/or sisters of the child:

Name:

Alex Smith

Age: 1:1 School:

N/A

Grade:______

Name:__________________________________ Age:_____ School:__________________________ Grade:______

Name:__________________________________ Age:_____ School:__________________________ Grade:______
Name:__________________________________ Age:_____ School:__________________________ Grade:______
FORM B 05

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Relatives or others living in the home:
Name:

N/A

Relationship:________________________________________

Name:_____________________________________ Relationship:________________________________________
Who referred you to the University of Arkansas Speech and Hearing Clinic?
Name:
II.

Dr. Benafield

Relationship:

Address: 3380 N. Futrall Drive

Statement of the Problem:

City:

Pediatrician________

Fayetteville

State:

AR

Zip: 72703

Describe the problem:

It is difficult to understand her speech.
When was the problem first noticed?
When Abigail first started talking we noticed something was different about her speech.
What has been done about it?
Nothing.
What is the childs reaction to the problem?
Abigail gets frustrated when people cannot understand her.
III.

Pregnancy and Birth History:

During this pregnancy did the mother experience any unusual illness, condition or accident? If so, describe:
No
Were there any complications during the delivery such as caesarean, extremely long labor, or use of instruments?
No

IV.

Developmental History:
At what age did the following occur?
Sat alone unsupported:

7 months

Crawled:

9 months

Maintained bowel and bladder control while awake:

26 months

Walked alone: 12 months

asleep:

33 months

Does the child seem awkward or uncoordinated? No

V.

Medical History:
Does your child have any long-term medical conditions for which they are now being or have been treated? No
Does your child take any medication regularly? No

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Has your child had a speech examination prior to this time? No
Where?__________________________________________________ When?_______________________________
What were the results?

Has your child had a hearing test prior to this time? Yes
Where?

Fayetteville Hearing Clinic

When? 12/12/14

What were the results?

Normal hearing.
Has your child had a neurological examination prior to this time? No
Where?__________________________________________________ When?_______________________________
What were the results?

Has your child had a psychological examination prior to this time? No

Where?__________________________________________________ When?_______________________________
What were the results?

Has your child had an eye examination prior to this time? No

Where?__________________________________________________ When?_______________________________
What were the results?

Has your child had a recent medical examination? Yes

Where?
Washington Regional
What were the results?

When? 1/29/15

Name of childs pediatrician/physician:

Dr. Benafield__________________________________________

Address:

3380 N Futrall Dr._______________________________________

City, State, Zip: Fayetteville, Arkansas

Phone #: 479-442-7322

72701_________________________________

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Check the following illnesses this child has had:
_____ Measles
_____ Mumps
_____ Whooping Cough
_____ Chicken Pox
_____ Scarlet Fever

_____ Influenza
_____ Meningitis
_____ Encephalitis
_____ Epilepsy
_____ Tonsillitis

_____ Draining Ears

_____Chronic Colds
X Allergies
_____ Sinus Problems
_____ Excessive Ear Wax

Has this child ever had earaches or ear infections? _____ Yes

_____ Head Injury

_____ Heart Disease
_____ Kidney Disease
_____ High Fever

No. If yes, how often and in

which ear(s)? ___________________________________________________________

How was it treated? ______________________________________________________
Has this child ever had a PE tubes, tonsillectomy and/or adenoidectomy? _____ Yes X No.
If yes, when ________________________ Physician _________________________________
Is there a history of hearing loss in the family? ________Yes
X No If yes, indicate which relative and at what age the
hearing loss was diagnosed. _________________________________________________________________________
________________________________________________________________________________________________
Has your child ever worn a hearing aid? ______Yes X No If yes, what kind of aid and in which ear (s)? _________
_________________________________________________________________________________________________

VI.

Daily Behavior:
Has your child been harder to manage than other children? No
Describe any unusual behavior:

Describe your childs interests:

Abigail loves playing with dolls, riding her tricycle, reading books, and watching Doc McStuffins.
VII.

Speech and Hearing History:

Does your child talk? Yes

If not, how does your child communicate?

When did your child first use words meaningfully?

Around 19 months.
When did your child begin to use two-word sentences?
Around 26 months.
Does your child understand what you say to him/her?
Yes
How well is s/he understood by parents?
Abigail is understood better by me (mom) than her dad, on certain words.

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By others?
Others have a hard time understanding Abigail at all, especially strangers.
Do you think your child hears adequately?
Yes
If not, what do you feel is the reason?
Has your child had frequent colds or ear problems?
No
VIII.

Educational History:
Has your child repeated any grades? N/A

If so, which ones?

With what subjects has your child had particular difficulties? N/A
Has your child ever had special help through the school? N/A
If so, please describe:
How does your child feel about school? Abigail enjoys going to preschool, but she gets frustrated when people
cannot understand her.