Case HX Form

To download the PDF version, click here.

Date (DDMMYYYY):

BACKGROUND INFORMATION
Child’s Name:

Date of Birth (DDMMYYYY):

Age:

Parent or Guardian Information
Name(s):

Email:

Age(s):

Occupation(s):

Does the child currently live with both parents?
YesNo
Telephone Numbers
Home:

Cell:

Work:

Best time to call:

Address:

City:

State (abbreviation):

Zip Code:

Reason for referral:

Who may we thank for referring you?

Names and ages of siblings:

Other adults living at home:

Child’s current educational placement (e.g., day care, preschool, school):

Contact information of educational placement:

How does your child’s teacher describe his/her performance?

Has your child’s teacher expressed any concerns in the areas of speech and language?
YesNo
Does your child currently receive special education services?
YesNo
If so, please describe.

If enrolled for special education services, has an Individualized Educational Plan (IEP) been developed?
YesNo
If so, please describe the goals:

How does your child handle frustration?

How does your child handle conflict?

How does your child handle separation?

What are some of your child’s favorite places?

What are some of your child’s favorite toys?

What are some of your child’s favorite activities?

What are some of your child’s favorite TV shows?

What are some of your child’s favorite snacks?

What motivates your child the most?

What discipline methods work best?

What language(s) does your child speak?

What is your child’s primary language?

What language(s) are spoken at home?

With whom does your child spend most of his or her time?

HISTORY OF CURRENT CONCERN
Please describe your child’s present speech/language difficulties

Who noted the present problem?

When was the present problem noticed?

What is your child’s reaction to the problem?

How does the family react to the problem?

Has there been a significant change in the past 6 months? Please describe.

How does your child usually communicate (e.g., gestures, single word phrases, short phrases, sentences)?

How well is your child understood by (i.e., what percentage of the time)

Mom:
90%80%70%60%50%40%30%<20%
Dad:
90%80%70%60%50%40%30%<20%
Younger Siblings:
90%80%70%60%50%40%30%<20%
Older Siblings:
90%80%70%60%50%40%30%<20%
Other Children:
90%80%70%60%50%40%30%<20%
Extended Family:
90%80%70%60%50%40%30%<20%
Unfamiliar Adults:
90%80%70%60%50%40%30%<20%
Please describe what it is like to have a conversation with your child:

How many words can your child say? Please provide examples.

How long are your child’s sentences? Please provide an example.

Does your child have any difficulty understanding you?
YesNo
Does your child have any difficulty following directions?
YesNo
Which speech sounds (if any) does your child have difficulty producing?
NONE/m//b//p//n//t//d//k//g//v//f//s//z//h/“ng” as in running“sh”“th”“ch”“juh” as in juice/w//l//r/“yuh” as in yes
Has your child been seen by any other speech and language specialists?
YesNo
If so, where?

By whom?

For how long?

Were any tests administered?
YesNo
If so, when?

What results were obtained?

What recommendations were made?

Has your child been seen by any other specialists?
YesNo
If so, by whom?

What results were obtained?

What were the specialist’s conclusions or suggestions?

Is there any history of speech/language/hearing difficulties in your family? Please describe.

PRENATAL HISTORY
What was the length of the pregnancy?

Were there any complications during pregnancy?

Were there any difficulties during birth?

MEDICAL HISTORY
Has your child suffered from any of the following illnesses/conditions?

NONEAllergiesAsthmaChicken PoChronic ColdConvulsionsCroupDizzinessEar InfectionsEncephalitisEnlarged GlandsHeadachesHigh FeverInfluenzaMeaslesMeningitisMumpsPneumoniaSeizuresSinusitisTinnitusTonsillitisHeart TroubleOther
Ages:

Please explain any checked items, including course of treatment:

Are your child’s immunizations current?
YesNo
Please describe your child’s general health:

Has your child had any operations (e.g., tonsillectomy, tube placement, etc.)?
YesNo
If so, please explain:

Has your child had any serious accidents requiring medical attention?
YesNo
If so, please explain:

Is your child currently taking any medication?
YesNo
If so, please indicate medication and dosage:

Has your child had any negative reactions to medication?
YesNo
If so, please identify:

Other medical history:

Primary Care Physician (PCP):

Contact information of PCP:

Date of last visit (DDMMYYYY):

DEVELOPMENTAL HISTORY
Please indicate the age at which your child:

Sat up alone:

Crawled:

Walked:

Toilet trained:

Dressed self:

Tied shoes:

Fed self independently:

Spoke first words:

Combined 2+ words:

Spoke in sentences:

Named simple objects (e.g., doggie, car, cookie):

Used simple questions (e.g., where’s mommy?):

Does your child have any difficulty sitting, walking, running, throwing or climbing?
YesNo
Does your child have any difficulty drawing, coloring, buttoning, zipping, or picking up small objects?
YesNo
Is your child:
Left HandedRight Handed
Has your child ever exhibited difficulty with feeding (e.g., sucking, swallowing, drooling, chewing)?
YesNo
What is your child’s sleep pattern like?

What is your child’s attention span like for self-directed activities?

What is your child’s attention span like for adult-directed activities?

Does your child respond to the following appropriately?

Light:
YesNo
Sound:
YesNo
People:
YesNo
Does your child play with others? If so, with whom?

What types of games does your child enjoy playing?

Does your child cry/laugh appropriately? Please explain.

How does your child make his/her wants known?

Does your child exhibit any unusual or repetitive behaviors (e.g., hitting, biting, hand flapping, screeching, rocking)?

How does your child react if a toy is taken away and hidden?

How does your child react if you are hurt?

OTHER
What do you hope to have happen as a result of this evaluation?

Is there anything else you would like to inform us of?

Person completing form:

Digital Signature (Parent or Legal Guardian):