Speech-Language History Form

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Email *

Child's Name *

Caregiver 1: *

Caregiver 1 Address *

Caregiver 2: *

Caregiver 2 Address *

Doctor's Name *

Birthdate *

YYYY

Sex *

Male

Female

Daytime Phone Caregiver 1 *

Cell Phone Caregiver 1 *

Email Caregiver 1 *

Daytime Phone Caregiver 2 *

Cell Phone Caregiver 2 *

Email Caregiver 2 *

Doctor's Phone Number *

Other children in the family? Please list their age, sex, grade level, and speech/hearing problems. *

Is there a language spoken in the home? *

Yes

If yes, which one? *

Does the child speak the language? *

Yes

Does the child understand the language? *

Yes

Who speaks the language? *

Which language does the child prefer to speak at home? *

Do you feel your child has a speech problem? *

Yes

If yes, please describe. *

Do you feel your child has a hearing problem? *

Yes

If yes, please describe. *

Has he/she ever had speech evaluation / screening? *

Yes

If yes, where and when? *

What were you told? *

Has he/she ever had a hearing evaluation / screening? *

Yes

If yes, where and when? *

What were you told? *

Has your child ever had speech therapy? *

Yes

If yes, where and when? *

What was he/she working on? *

Has your child received any other evaluation or therapy? (Physical therapy, counseling, occupational therapy, vision, etc.) *

Yes

If yes, please describe. *

Can your child read? *

Can your child write? *

Is your child aware of, or frustrated by, any speech/language difficulties? *

What do you see as your child's most difficult problem in the home? *

What do you see as your child's most difficult problem in school? *

BIRTH HISTORY

Was there anything unusual about the pregnancy or birth? *

Yes

If yes, please describe. *

How old was the mother when the child was born? *

Was the mother sick during the pregnancy? *

Yes

If yes, please describe. *

How many months was the pregnancy? *

Did the child go home with his/her mother from the hospital? *

Yes

If the child stayed in the hospital, please describe why and how long. *

Birthweight (pounds and ounces) *

Type of delivery? *

MEDICAL HISTORY

Does your child have a diagnosis and if so what is it? *

What is the onset date of the diagnosis? *

Has your child had a frenectomy / tongue or tip tie release? *

Yes

When? *

Has your child had any of the following? *

adenoidectomy

allergies

breathing difficulties

chicken pox

colds

ear infections

ear tubes

encephalitis

flu

head injury

high fevers

measles

meningitis

mumps

scarlet fever

seizures

sinusitis

sleeping difficulties

thumb / finger sucking habit

tonsillectomy

tonsillitis

vision problems

Required

If checked yes for ear infections, how often? *

Other serious injury / surgery? *

Is your child currently (or recently) under a physician's care? *

Yes

If yes, why? *

Please list any medications your child takes regularly. *

DEVELOPMENTAL HISTORY

At what age did your child first sit alone? *

At what age did your child fist babble? *

At what age did your child start putting two words together? *

At what age did your child start walking? *

At what age did your child first grasp a crayon or pencil? *

At what age did you child say their first words? *

At what age did your child first speak in short sentences? *

At what age was your child toilet trained? *

Does your child... *

choke on food or liquids?

currently put toys / objects in his or her mouth?

brush his or her teeth and or allow brushing?

Required

SCHOOL HISTORY

If your child is in school, please answer the following questions.

Name of school and grade in school *

Teacher's name *

Has your child repeated a grade? *

What are your child's strengths and or best subjects? *

Is your child having difficulty with any subjects? *

Is your child receiving help in any subjects? *

CURRENT SPEECH-LANGUAGE

Does your child... *

repeat sounds, words, or phrases over and over?

understand what you are saying?

retrieve / point to common objects upon request (ball, cup, shoe)?

follow simple directions ("Shut the door" or "Get your shoes")?

respond correctly to yes/no questions?

respond correctly to who/what/where/when/why questions?

Required

Your child currently communicates using... *

body language

sounds (vowels, grunting)

words (shoe, doggy, up)

2-4 word sentences

sentences longer than 4 words

Other:

Required

If you selected other in the question above, please explain. *

Behavioral Characteristics *

cooperative

attentive

willing to try new activities

plays alone for reasonable length of time

separation difficulties

easily frustrated / impulsive

stubborn

restless

poor eye contact

easily distracted / short attention span

destructive / aggressive

withdrawn

inappropriate behavior

self-abusive behavior

Required

ADDITIONAL QUESTIONS FOR SPEECH EVALUATION

What are your concerns regarding your child's speech and language? *

How does your child communicate his or her wants / needs? *

Are you and others able to understand your child speech? *

Yes

What percentage of the time? *

What would you like to see as an outcome for speech therapy and what are YOUR goals for your child? *

Is your child a picky eater? *

Yes

Does your child eat at least 10 foods from each of the following categories? (protein/dairy, fruits/vegetables, starches) *

Yes

If no, please list any food items your child consumes under each category (protein/dairy, fruits/vegetables, starches). *

If your child is coming for a feeding evaluation, please bring the following with you to the appointment: 4-5 non preferred foods and 2-3 preferred foods / drinks.

A copy of your responses will be emailed to the address you provided.

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