History/Consent

Date:*

Date

Child's Name:*

Date of Birth:*

Date

Parent/Guardian Names:*

Cell Phone:*

Email*

example@example.com

Wee Speech uses email as the means to communicate information about clinic happenings. Please be sure to read the newsletters to learn about upcoming events, closings, scheduling, etc.

Home Address:

Type a question

City, State, Zip:*

Name and age of Siblings:

Emergency Number:*

Daycare/School:

Address:

Teacher:

Phone:

School Speech Pathologist:

Phone number:

Pediatrician:*

City, State, Zip:*

Fax:

Who referred you to Wee Speech?*

What concerns you about your child's speech and language? How long have you been concerned? Please provide an example.*

Has your child ever been given a medical diagnosis?*

By Whom?

What was the diagnosis?

Is your child currently receiving therapy services (e.g. another clinic, Early Intervention)?*

Has your child ever received therapy? If yes, what type and frequency?*

Does any other family members have speech and language disorder/ difficulties? If so, please explain.*

What is your child's primary language? Are there additional languages spoken in the home?*

If so, does your child exhibit difficulties in both languages?

Length of pregnancy:*

Length of labor and type of delivery:*

If there were complications, what medications or treatment were required?

Was an extended stay at the hospital required for mother or baby?

Was your child breast or bottle fed? For how long? Any difficulties or complications?*

Difficulty swallowing or initiating feeding (difficulty latching to nipple, spitting up/vomiting)?*

Has your child ever had a feeding tube? If so for how long?

Started solids when? Any difficulties managing the introduction of solids?*

Does your child feed himself/herself independently using utensils?*

What are preferred and non-preferred foods?*

Held head erect:*

Followed objects with eyes:*

Noticed noises:*

Reached for objects:*

Sat alone:*

Stood alone:*

Walked:*

Imitated sounds:*

First word: At what age ? What were the words?*

Two and three word sentences:*

Followed simple directions:*

Bladder and bowel trained day/night:*

Has your child ever had a hospital stay? If yes, for what and how long?*

Has your child ever had surgery? If yes, for what?*

Has your child had ear infections? Frequency?*

Does your child now or has your child in the past had drainage tubes placed?*

What is your child's current hearing status?*

Does your child wear glasses? Nearsighted/Farsighted*

Please list any allergies your child may have including allergies to food as food may be used in treatment:*

Please list any other dietary restrictions:

Is your child on any medication? Please list the name and purpose of each medication.*

Sleeping:*

Eating (e.g. current diet, mealtime habits)*

Gross Motor (e.g. walking, running, balance, throwing ball, ):*

Toilet habits:*

Speaking:*

Playing alone:*

Playing with others:*

Fine Motor (e.g. coloring, writing, cutting, etc).*

Day Care/School (e.g. describe how your child performs, any supports needed ):*

How does your child communicate his/her wants and needs? Sounds/gestures/words. Please elaborate:*

Please list any behaviors that your child exhibits during moments of frustration:*

Has your child had any exposure to computers or other types of technologies (i.e. iPad, tablet, e reader)? Please describe:*

Does your child recognize pictures? Read words? Spell?*

Are there any toys or activities that your child is fearful of?*

Describe toys and activities that your child enjoys:*

What are your specific communication goals for your child?*

Please share any other information that you feel is relevant.

Please attach any reports that you feel are important (e.g. IEP, Early Intervention, Neuropsychological testing, previous therapy/school reports) . Thank you

Browse Files

Client History

PREGNANCY

FEEDING

DEVELOPMENT

HEALTH

DESCRIBE YOUR CHILD'S BEHAVIOR IN THESE AREAS

COMMUNICATION