Welch-schmidt center for communication disorders



Download 279.5 Kb.
Date21.07.2018
Size279.5 Kb.
WELCH-SCHMIDT CENTER FOR COMMUNICATION DISORDERS

MARTIN 34

WARRENSBURG, MISSOURI 64093

Phone: 660-543-4993 Fax: 660-543-8234



Stuttering Case History Form

(This form is supplemental to Adult/Child Speech Case history form)



History of Stuttering


Give approximate age at which stuttering was first noticed ______________________________

Who first noticed or mentioned the stuttering? _______________________________________

In what situation was the stuttering first noticed? _____________________________________

Describe any situations or conditions that might be associated with the onset of stuttering______

____________________________________________________________________________

_____________________________________________________________________________


Under what circumstances did the stuttering occur after initial onset? ______________________

____________________________________________________________________________


Were the first signs of stuttering (check all that apply)



movement) but no sound forthcoming


Was the stuttering always the same, or did it occur in several different ways? _______________

If it occurred in different ways, how were they different from one another? Describe__________

_____________________________________________________________________________

Approximately how long did each block (on one word) seem to last? ______________________

Was the stuttering easy or was there force at the time when the stuttering was first noticed? ____

_____________________________________________________________________________

Were the words that were stuttered at the beginning of sentences, or were they scattered throughout the sentence being said? ________________________________________________________

_____________________________________________________________________________

When stuttering first began, was there any avoidance of speaking because of it? Give examples, if any._________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
At the time when stuttering was first noticed, what was the child’s reaction? (check all that apply)



Other? Describe ________________________________________________________________


What attempts have been made to treat the stuttering problem (either formally or informally)?

_____________________________________________________________________________

_____________________________________________________________________________

Does the child have articulation or pronunciation problems in addition to stuttering? If so, please describe ______________________________________________________________________

_____________________________________________________________________________

Development of Stuttering


Since the onset of stuttering, has there been any change in stuttering symptoms? Check those that apply:







(if voice has been present)?

Describe any of the above that apply________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
Were there any periods (weeks / months) when the stuttering disappeared? _________________

_____________________________________________________________________________

Were there any periods (weeks / months) when the stuttering increased? ___________________

_____________________________________________________________________________

Can you give any explanation for these “worse” periods? _______________________________

_____________________________________________________________________________

Are there any situations that are particularly difficult? If so, describe _______________________

_____________________________________________________________________________

List any situations that never cause difficulty _________________________________________

_____________________________________________________________________________


Answer “yes” or “no” to the following as they apply to your (your child’s) stuttering:

Yes No Yes No










_____________________________________________________________________________


Do you feel that stuttering interferes with your (your child’s):

(circle Yes or No) Y / N daily life? Y / N Social relationships? Y / N Success in school?



Page of


Share with your friends:


The database is protected by copyright ©dentisty.org 2019
send message

    Main page