Super Duper® Publications • 1-800-277-8737 • www.superduperinc.com Developmental History Please tell the approximate age your child achieved the following developmental milestones: …

Speech Assessment Case History Form (page 2) Was the child born premature? YES Was the child healthy at birth?

In your own words, describe your speech/language or hearing problem. When was the problem first noticed? By whom? What do you think caused or is causing the problem? What have you …

A Case History Form is a document used by healthcare providers, including doctors, nurses, and other medical staff, to gather comprehensive information about a patient's medical history, …

Medical History Please check any of the following which the child has experienced or which the child has been diagnosed.

To assist us with learning more about your child’s communication skills, please complete the following form. Write NA in the questions that do not apply to your child.

Describe any major accidents, and any significant changes that resulted. Provide any additional information that might be helpful in the evaluation or remediation process.