New Pediatric Patient Registration Form

New Patient Registration

Please fill in the form below.
Patient Information

Please answer each question to the best of your knowledge.
Patient Name *

First Name Middle Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth *

Month Day Year
Referred By: *

First Name Last Name
Parent/ Guardian Name *

First Name Last Name
Parent Email Address *
Primary Language Spoken *

English Spanish Other
Patient Sex *
Primary Concern for Appointment *

Speech/Language Feeding/Swallowing
Medical History

Please complete each question to the best of your knowledge.
Pediatrician's Name *

First Name Last Name
Pediatrician's Phone *

Area Code Phone Number
What was the mother's length of pregnancy with the patient? *

37-40 weeks 30-36 weeks 25-29 weeks 25 < weeks
Was the mother's labor: *

Spontaneous Induced Vaginal C-Section
If yes, which medications or drugs were used? *
Patient's birth weight (pounds) *
Did any of the following complications apply at time of birth? *

Jaundice Prolonged Stay at NICU Low birth weight Blue color Respiratory Difficulties Sucking/Swallowing difficulties Infection of baby or mother Breech Birth Failed NBHS Nuchal Cord AIDS/ HIV Heart/Cardiovascular Low APGAR SCORE CMV None of these
Has the patient experienced any of the following medical complications? *

AIDS/HIV Autism Asthma Allergy/Sinus Problems Developmental Delay Short Attention Span Measles Tonsilitis Scarlet Fever Gastrointestinal Problems ADHD/ ADD Blood Disorder Cancer Chicken Pox Genetic Disorders Diabetes Influenza Meningitis Malaria Speech Delay Endocrine System Disorder Physical Impairment Headaches Head Injury Hearing Loss Heart Problems Ear Infections Behavioral Disorder Vision loss UTI Stroke Neurologic Disorder Learning Disability None of these
Additional Medical History/Symptoms *
Is the patient currently taking any medication? *

Yes No
If yes, please list it here *
Speech- Language History
What is your primary concern regarding the patient's speech/language? *

Early Language Delay Articulation Language/Literacy Fluency Other None of these
If other, please list the concern below. *
If no, please explain why you do not believe the patient's speech is normal. *
When did the patient say his/her first word? *

12 months 24 months Greater than 24 months My child is not speaking at this time
Approximately how many total words does the patient use?
If yes, please list all food allergies.
If no, please describe the patient's diet. *
Hearing Health History
Please provide the date of your child's most recent doctor's appointment.

Month Day Year
Date
If not, what seems abnormal about the patient's hearing? *
If yes, what type of hearing aid? *

Behind the ear CROS BAHA Cochlear Implant
Academic History
If so, what school does the patient attend? *
What grade is the patient currently in? *
What is the patient's grade point average? *

A B C D F Other Not Applicable
If yes, what type of assistance does the patient receive in school? *
Should be Empty:

New Patient Registration

Patient Information

Medical History

Speech- Language History

Hearing Health History

Academic History