A. Meric O'Grady - Speech and Language Pathology

Child's Name

Age

Birthdate

Mother's Name

Mother's Occupation

Father's Name

Father's Occupation

Length of Pregnancy

Birth Weight

Complications During Birth?

Please explain any difficulties experienced during pregnancy

Sucking Difficulties?

Feeding Difficulties?

Reflux?

Lack of Oxygen?

Breathing Difficulties?

Head Injuries?

Fetal Monitor Use?

Turn Over

Sit Up

Crawl

Walk Alone

Babble

First Words

Combine Words

Sentences

Toilet Trained

Feed Self

Dress Self

Right-handed or Left?

At what age did handedness develop?

Did your child have sucking difficulties after birth? Yes No

If you answered yes to the above, please answer the following questions to the best of your ability:

Stage 1 Baby Foods

Stage 2 Baby Foods

Stage 3 Baby Foods

Finger
Foods

Table
Foods

Does your child eat the same meal as the rest of the family? Yes No

Do you or others consider your child a “picky eater”? Yes No

Is one or both parents considered a “picky eater”? Yes No

Does your child cough or gag 1 or more times during mealtimes? Yes No

Does your child’s nose drip during meal times? Yes No

Does your child tolerate tooth brushing? Yes No

Does your child have any food allergies? Yes No

A. Meric O'Grady
Speech and Language Pathology LLC

Child Case History Form

Child Information

Family Information

Birth history

Development History

Feeding History

Medical History

Speech History

A. Meric O'Grady Speech and Language Pathology LLC