Get the free Speech-Language-Hearing Case History Form

Speech-Language-Hearing Case History Form Identifying Information: Child s Name: Date of Birth: Parent s Name (s): Home Phone : Home Address: Cell Phone: Work Phone: Parent s Occupation: Email Address:

How to fill out speech-language-hearing case history form

How to Fill Out a Speech-Language-Hearing Case History Form:

1. Start by providing personal information such as your name, age, and contact details. This will help the speech-language pathologist or audiologist to address you properly and contact you if needed.
2. Include information about your medical history, including any current or past illnesses, injuries, or surgeries. Mention any chronic conditions or medication you are currently taking, as they may have an impact on your speech, language, or hearing abilities.
3. Specify any previous speech-language-hearing evaluations or treatments you have undergone. This information is essential for the clinician to understand your previous experiences and determine the appropriate course of action.
4. Provide detailed information about your speech and language skills. Describe any difficulties you may have noticed, such as problems with articulation, fluency, vocabulary, grammar, or comprehension. Include any speech or language therapy you have received in the past.
5. Mention any hearing-related concerns you may have. Include details about any hearing loss you have experienced, whether it's in one or both ears, and if it was gradual or sudden. Indicate if you wear hearing aids or other hearing devices.
6. Describe any communication challenges you face in different environments such as at home, school, work, or social gatherings. It is important to mention any specific situations or activities where you have difficulty understanding or effectively expressing yourself.
7. Include information about your educational, occupational, and social background. This can help the clinician understand how your communication abilities may impact your daily life, academic performance, or career goals.
8. Note any additional concerns or questions you may have, related to your speech, language, or hearing. This can range from specific communication problems to goals you hope to achieve through therapy.

Who needs a Speech-Language-Hearing Case History Form:

1. Individuals seeking evaluation or treatment for speech, language, or hearing difficulties or disorders will need to fill out a case history form. This typically includes children, adolescents, and adults of all ages.
2. Parents or legal guardians may need to complete the form on behalf of young children who are not yet capable of providing their own information.
3. Individuals who suspect they have communication difficulties or need assistance with their speech, language, or hearing abilities can also benefit from filling out a case history form. This includes individuals who may have had previous evaluations or treatments but require updated information for ongoing care.

The speech-language-hearing case history form serves as a valuable tool in assessing an individual's communication needs, guiding the evaluation process, and tailoring appropriate interventions.

For pdfFiller’s FAQs

What is speech-language-hearing case history form?

Speech-language-hearing case history form is a document that gathers relevant information about a patient's medical history, communication difficulties, and hearing-related issues.

Who is required to file speech-language-hearing case history form?

Speech-language pathologists, audiologists, and other healthcare professionals are required to file speech-language-hearing case history form for their patients.

How to fill out speech-language-hearing case history form?

To fill out the form, healthcare professionals need to gather information about the patient's medical history, communication difficulties, hearing-related issues, and any relevant family history.

What is the purpose of speech-language-hearing case history form?

The purpose of the form is to help healthcare professionals assess and diagnose communication and hearing disorders accurately.

What information must be reported on speech-language-hearing case history form?

The form must include information about the patient's medical history, communication difficulties, hearing-related issues, and any relevant family history.

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