Please enable JavaScript in your browser to complete this form.1General Information2Health and Developmental History3Voice and Fluency4Auditory Processing and Learning5Sensory and Motor6Behavior7Other InformationToday's Date:Child's Name: *FirstLastGender: *MaleFemaleDate of Birth: *Address: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent Name: *FirstLastEmail: *Occupation:Parent Name: FirstLastEmail: Occupation: Primary language spoken at home:Names and ages of those living in the home:Referred by: *Pediatrician Name: *FirstLastPediatrician Phone Number:Please indicate any concerns you have for your child in the following area(s):ArticulationReceptive languageExpressive languageSocial skillsAuditory processingStuttering / fluencyMouth breathingNot talking yetLimited number of wordsNot putting words together Basic conceptsFeeding / swallowing difficulties Following simple directionsOrofacial myofunctional disorderPoor memoryReading comprehensionVoice qualityWord finding Attention / focusBehaviorReferred by medical / dental professionalWhen did you first notice the problem(s) indicated above?Does anyone in your family history have a speech, language, hearing or learning problem that you are aware of?YesNoIf yes, please describe:NextDid you have a typical pregnancy?YesNoLength of Pregnancy:Please list any complications:Medications used during pregnancy?Describe your child's delivery and birth:TypicalSpontaneousInducedCesareanBreechUnusually long laborDuration of labor:(Hours)Medication used during labor:What was your child's birth weight?APGAR score:What was your child's condition at birth?Typical Birth injury / defectJaundicedBreathing problemLow birth weightOther:Does your child have a history of any of the following: (check all that apply)Drooling Chronic ear infectionsAllergiesAsthmaHearing lossEar tubesSurgeryChronic or severe illnessHigh or prolonged feversRefluxIntubation / ventilatorHospitalizationSeizuresHead injurySerious accidentPlease explain any of the above as needed.Has your child ever been hospitalized? How long?List any medication(s) your child is currently taking:Has your child received all of the vaccinations recommended by your pediatrician?YesNoHas your child ever had a hearing evaluation?YesNoIf yes, list dates and results:Does your child have a history of feeding problems?YesNoIf yes, check all that apply:Choking / coughingNursing difficultiesDifficulty biting Difficulty chewingGagging / vomitingDifficulty swallowingDoes your child have a history of trouble sleeping through the night?YesNoIs your child a messy or picky eater?YesNoPlease list favorite foods:Please list food sensitivities:At what age did your child attain these developmental milestones?Sitting:First words:Crawling:Walking:Toilet training:First sentences:PreviousNextIs your child's voice clear?YesNoIf no, please describe:Describe your child's voice: (check all that apply, if any)NasalDenasal (sounds like s/he has a cold)LoudSoftHigh-pitchedLow-pitchedMonotoneBreathyHoarseDoes your child talk smoothly without repeating sounds or words?YesNoIf no, does s/he have trouble getting words out?YesNoIf yes, please describe:PreviousNextDoes your child have difficulty with any of the following? (check all that apply)Memory tasksComprehensionWord retrievalHearing difficultiesListening with background noiseReading difficultiesSpelling / writing difficultiesPhonologic / phonemic difficultiesLearning difficultiesRemembering and following multi-step directionsPutting thoughts togetherDifficulty learning or using new vocabulary Auditory attentionAcademic under-achievementHypersensitivity to loud soundsWord-finding difficultiesAuditory distractibilityOrganization and planningDoes your child receive any services at school (IEP or 504 plan) or outside help?YesNoIf yes, please list all:Can your child retell a simple story in a sequence?YesNoCan your child identify steps to complete a simple task? (e.g. brushing teeth, setting the table)YesNoDoes your child appear to attend to your face when listening?YesNoDoes your child appear to become easily distracted when listening?YesNoDoes your child appear to be confused with listening?YesNoDoes your child appear to be particularly uncomfortable in house (as compared to same aged peers)?YesNoPreviousNextDoes (or did) your child have any difficulty walking, running, sitting or with any large motor skills?YesNoIf yes, please describe:Does (or did) your child tippy-toe walk?YesNoIs (or was) your child clumsy or does s/he fall easily?YesNoDoes (or did) your child have difficulty with fine motor skills such as stacking, cutting and handwriting?YesNoDoes (or did) your child have low body tone?YesNoIs (or was) your child sensitive to certain textures of food or clothingYesNoIf yes, please describe:Check all that apply regarding your child, if any.Dislikes washing his/her hair or faceDislikes haircutsSpends too little time or too much time brushing his/her teethDoes not demonstrate cautionPuts things in his/her mouth besides foodChews on his/her clothesNextDoes your child typically display any of the following behaviors? (check all that apply)Reduced or lack of interaction with othersTantrumsPassive in interactionsVery activeUnder-activeInattentiveRefuses to perform tasksDifficulty staying on taskDifficulty finishing tasksSensitiveAngry/acting out behaviorFrustratedShyPreviousNextDoes your child have any of the following health problems?SnoringDaytime tirednessOpen-mouth breathingAllergies/asthmaADHDCleft lip / palateLispNoisy breathing at nightDifficulty concentratingDifficulty breathing through noseOften sick with colds / infectionsAutism Spectrum DisorderHearing / vision difficultiesRestless sleep Bed-wettingEar,nose,throat infectionsDevelopmental delaysSensory sensitivitiesChronic stutterOther:Please answer Yes or No to the following questions. If you are unsure just leave the answer blank.Any additional information you can provide is appreciated.Does your child go to bed unwillingly? YesNoDoes your child express fear or worries before going to bed?YesNoDoes your child complain about difficulties falling asleep at night?YesNoIs your child a restless sleeper?YesNoDoes your child wake up at night?YesNoDoes your child get up to go to the bathroom at night?YesNoIs your child primarily a mouth-breather?YesNoDoes your child have nightmares?YesNoDoes your child have a problem with bed-wetting?YesNoDoes your child stop breathing during sleep?YesNoDoes your child sweat more than usual during sleep?YesNoDoes your child have problems with anxiety or behavioral issues?YesNoDoes your child have difficulty breathing during sleep?YesNoIs your child sleepy during the day?YesNoDoes your child complain about tiredness / sleepiness?YesNoDoes your child chew with their mouth open / messy eater?YesNoDoes your child chew or bite on a pencil, hair, nail, etc?YesNoWho does your child live with? (Check all that apply)Both parentsMother onlyFather onlyParent & stepparentGrandparentsFoster parentsOther:What languages are spoken in the home?EnglishSpanishOther:Has your child been evaluated by any other professional? (Check all that apply)Speech-language Pathologist Occupational Therapist (OT)Physical Therapist (PT)Developmental Pediatrician Psychologies/PsychiatristEducator/TeacherNeurologistPhysician GeneticistOther:Does your child have a diagnosis from any of the above professionals?YesNoIf yes, please list date, professional and diagnosis for each:Has your child had previous Speech-Language Therapy, Occupational Therapy or Physical Therapy?YesNoIf yes, please describe the goals and outcome of therapy:What other concerns do you have about your child?What do you consider to be your child's greatest strenght?What do you hope to gain from this evaluation?PreviousNameSubmit
