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)

Health Questions (surgeries/ illnesses)

Rows	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:

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

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

Behavioral Characteristics I notice in my child: (check all that apply)

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)

Rows	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)

Rows	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:

My child ...

What daycare/ school does your child attend?

school/ grade

Appointment time needed: (please choose all that apply)

Additional comments or concerns: