Patient Screening Form

Patient Screening Form
Birth History:
How many weeks was the pregnancy?
Were there any complications during the delivery?
If yes, explain otherwise leave this blank
Other children in the family:
Include: Name/ Age/ Sex/ Grade/ Speech, Hearing, PT, OT needs:
Is there a family history of speech or other disorders?
Include: Who? What disorder? (father, stutter)
Health questions about your child: (check all that apply)

History of high fevers Feeding Difficulties History of Seizures Breathing difficulties Head injury Sleep difficulties Pacifier use/ nail biting Thumb/ finger sucking habit Vision problems Difficulty with bottle/ breastfeeding Uses orthotics/ adaptive equipment Puts toys/ objects in their mouth

Health Questions (surgeries/ illnesses)

	Yes	No	When / Date
Frequent Ear Infections?
Adenoids/ Tonsils removed?
Ear Tubes?
Other? (ex. Strep, every 8 weeks since 1 year old)

Health Questions continued:

	Yes	No	Please list
Medications (please list)
Allergies (please list)

My child usually communicates using: (check all that apply)

Body Language (pointing, expressions) Sentences longer than 4 words Words (shoe, doggy, up) 2 to 4 word sentences Sounds (vowels, grunting, crying)
Behavioral Characteristics I notice in my child: (check all that apply)

Cooperative Willing to try new activities Plays alone for period of time Self abusive behaviors Easily frustrated/ impulsive Stubborn Destructive/ aggressive Poor eye contact

My child achieved these Developmental Milestones at this age... *

Activities of living: (check the level that applies to each skill) *

Age specific behavioral questions for children of ALL ages: (select the frequency of each behavior) *

	Consistent	Sometimes	Never
Gives eye contact to family, friends, etc.
Responds to greetings (waves, says hello)
Follows verbal commands (stop, get your shoes)
Interacts with family
Interacts with same age peers
Responds to name

OVER 3 ONLY: Age specific behavioral questions for children (select the frequency of each behavior) *

	Consistent	Sometimes	Never
Takes turns in games
Takes turns in conversations
Stays on topic of conversation
Answers who, what, where and when questions

Hand Preference: *

Left Hand Dominant Right Hand Dominant Uses both Unknown
My child ...

has an IEP, IFSP, EFSP or 504 plan? has a current hearing screening? receives therapy at another clinic?
What daycare/ school does your child attend?
school/ grade

Appointment time needed: (please choose all that apply)

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