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061 334023 | info@downsyndromelimerick.ie

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Contact Us
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SLT Case History Form

To be completed by parent/guardian

Background Information:

Name of Child *

Date of Birth

Age

Mother's Name

Father's Name

Mother's Address

Father's Address (if different)

Telephone (home)

Mobile / Emergency Number

Siblings (names and ages)

Does your child have any medical conditions? (incl. allergies) *YesNo

Please list medical conditions (incl. allergies)

Is your child currently on any medication? *YesNo

Please state names and dosage.

Date of most recent hearing test

Results from hearing testNormal HearingHearing Loss InidicatedBlocked EardrumsOther

Please state Other

Date of most recent eye test

Results from eye testNormal VisionVisual Difficulties

Please give details

Paediatric Link Worker

Early Intervention or Children’s Services Team

GP

Current Speech and Language Therapist (SLT)

Have you attended any of the followingHanen trainingLámh training

Recent Intervention (SLT, Physiotherapist, Occupational Therapist, and Psychologist):

Crèche/Preschool/School Attending:

Class and Teacher

Resource Teacher

SNA

Birth History

Please give any relevant details of the pregnancy

BirthFull-TermPrematureNVDInducedCaesarean

When was the diagnosis of DS made?

Birth Weight

Post Natal

Early Feeding

Medical History

General Health

Hospitalisations

Milestones

Please enter at what age your child reached the following milestones.

Sitting

Crawling

Walking Independently

Toilet Training

Feeding self with spoon

Eating solid food

Early Language Development

Did your child babble as a baby?YesNo

At what age did your child say his/her first words?

How does your child communicate at home?Makes soundsGesturesLámh signsSpoken words

Does your child get frustrated if they are not understood?YesNo

Does your child imitate ever imitate:ActionsSoundsWords

Does your child make choices between two or more things?YesNo

Motor Skills

(Please comment on your child’s coordination, clumsiness, falls, slow/fast in activities e.g., walking, running, climbing, riding bikes etc and fine motor skills in colouring, cutting, writing, drawing, feeding etc.)

Motor Skills

Socialisation & Play

What does your child like to play with?

Do they play by themselves or with others?

Opportunities for socialisation with other children?

Personality(shy/outgoing, particular fears, likes/dislikes, social, outgoing, temperament)

Family History

Are there any incidences of the following conditions among the child’s family/close relatives (maternal & paternal)?Speech difficultiesHearing difficultiesLearning disabilitiesSeizures/convulsionsAutism/spectrum disorder

Please comment

Education(school progress, interaction with others, IEP goals if developed)

Education

Behaviour(including attention/listening and behaviour management)

Behaviour

What are your current concerns regarding his/her speech and language abilities now?

What would you like him/her to achieve from attending Speech & Language Therapy?

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Limerick,
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061 334023
info@downsyndromelimerick.ie

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