speech language case history form

3 min read 02-02-2025

This guide provides a detailed overview of a comprehensive speech-language case history form, outlining essential sections and considerations for clinicians. A well-structured case history form is crucial for accurate diagnosis and effective intervention planning. This form aims to gather relevant information from various sources to build a holistic understanding of the client's communication abilities and related challenges.

I. Identifying Information

This section captures essential demographic details, forming the foundation of the client's file.

Client Name & Date of Birth: Basic identification information.
Address & Contact Information: Essential for scheduling and communication.
Referring Physician/Professional: Details of the professional who initiated the referral and their contact information.
Date of Evaluation: Record the date the assessment commenced.
Interpreter Needed (if applicable): Note if an interpreter is required and specify the language.
Emergency Contact: Include name, relationship, and contact information for emergencies.

II. Presenting Complaint & Reason for Referral

This section focuses on the reason for the referral, clearly articulating the concerns.

Parent/Guardian Concerns (if applicable): Detailed description of the concerns expressed by the client's parents or guardians. Include specific examples and the onset of concerns.
Client's Self-Report (if applicable): If the client is old enough, include their perception of their communication difficulties.
Referring Physician/Professional's Report: A summary of the referring professional's observations and recommendations.
Specific Areas of Concern: Clearly state the suspected communication difficulties, such as articulation, fluency, language comprehension, social communication, voice, or swallowing.

III. Developmental History

Understanding developmental milestones is crucial for identifying potential delays or atypical patterns.

Prenatal History: Information regarding the mother's health during pregnancy, including any complications or medications.
Perinatal History: Details of the birth process, including gestational age, birth weight, and any complications.
Postnatal History: Information about the child's early development, including milestones such as sitting, crawling, and walking. Note any significant illnesses or hospitalizations.
Medical History: Complete medical history, including current medications, allergies, and significant past illnesses or surgeries. This should also include any diagnoses relevant to communication such as Autism Spectrum Disorder, Cerebral Palsy, or Traumatic Brain Injury.

IV. Educational/Occupational History

This section assesses the impact of communication on the client's academic or professional life.

Educational Background: Information about the client's current educational placement, academic performance, and any support services received.
Occupational History: For adult clients, gather information about their work history, job performance, and any communication-related challenges faced in their workplace.

V. Social & Communication History

This is a critical section focusing on the client's social interaction and communication skills.

Family Communication Patterns: Describe the family's communication style and language use.
Social Interactions: Describe the client's social skills, including interactions with peers and adults. Note any difficulties with social communication, such as initiating conversations, maintaining eye contact, or understanding nonverbal cues.
Language Use at Home & School/Work: Detail language use in different environments, noting any differences in communication abilities across settings.
Leisure Activities: Identify the client's hobbies and interests, assessing their impact on communication skills.

VI. Speech-Language Assessment

This section summarizes the results of the formal and informal assessments conducted.

Articulation: Details of articulation testing, including phonetic inventory, error patterns, and intelligibility.
Language: Assessment of receptive and expressive language skills, including vocabulary, grammar, and narrative skills.
Fluency: Assessment of fluency, identifying any stuttering or cluttering behaviors.
Voice: Evaluation of voice quality, pitch, loudness, and resonance.
Oral Motor Skills: Assessment of oral-motor structure and function, including lip, tongue, and jaw movements.
Cognitive-Communication: Assessment of cognitive aspects impacting communication, such as memory, attention, and executive functions.
Social Communication: Assessment of the client’s social communication skills, such as initiating conversations, understanding nonverbal cues and perspective-taking.

VII. Prognosis & Recommendations

This concluding section summarizes the findings and outlines recommendations for intervention.

Diagnosis: A clear and concise statement of the client's communication diagnosis.
Prognosis: An estimate of the client's potential for improvement with intervention.
Recommendations: Specific recommendations for treatment, including frequency, duration, and goals. Include referrals to other professionals as needed.

This comprehensive speech-language case history form ensures a thorough understanding of the client's communication abilities and needs, leading to effective intervention planning and improved outcomes. Remember to adapt this framework based on the individual client's age, needs, and specific communication challenges. Always maintain client confidentiality and adhere to ethical guidelines.