New Pediatric Patient Registration Form

SPEECH MATTERS

Specialize in Speech Therapy for Children and Adults.
New Client Registration

Please answer each question to the best of your knowledge
Client and Family Information
Full Name*
Name as per official Document
Birth Certificate No / FIN
Starts with T or G
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemale
Name of Parent / Guardian*
Name as per official Document
Name of Parent / Guardian*
Name as per official Document
Parent Email Address*
example@example.com
Parent Email Address
example@example.com - Optional field
Preferred Phone number*
Phone number
Alternative Phone number*
Phone number
Primary Language (s) Spoken*

EnglishMandarin / ChineseMalay (Bahasa Melayu / IndonesiaTamil / HindiOther
Primary Concern*

Speech / LanguageCommunicationFeeding /Swallowing difficultiesVoiceOther
If other, please fill in the primary reason for the appointment.
Referred by*

Self referredFriend / FamilySchool / TeacherDoctor / Therapist / Psychologist
Name of Dr (or Clinic) / Therapist / Psychologist
Medical History

Please complete each question to the best of your knowledge.
What was the mother's length of pregnancy with the patient?*

37-40 weeks30-36 weeks25-29 weeks25 < weeks
Delivery Information*

Natural Birth / VaginalInducedAssisted (Forceps / Vacuum)C-Section
Did any of the following complications apply at time of birth?*

JaundiceProlonged Stay at NICULow birth weightBreathing DifficultiesSucking/Swallowing difficultiesInfection of baby or motherComplications at BirthHeart/CardiovascularLow APGAR SCOREHypoxia / Low Oxygen LevelsNone of theseOther
Has your child experienced any of the following medical complications?*

AsthmaCancerGenetic DisordersDiabetesMeningitisPhysical ImpairmentBrain InjuryHearing LossEar InfectionsVision lossStrokeCerebral PalsyNone of these
Does your child have any of the following?*

Autism Spectrum DisorderDevelopmental DelayShort Attention SpanADHD/ ADDSpeech DelayMotor Development DelayBehavioural DisorderSensory ChallengesFeeding ChallengesLearning DisabilityNone of these
Additional Medical History/Symptoms
Child Development History Information

Fill in this section to the best of your ability. It would provide information on factors which may affect your child's communication or learning development.
Motor Development Milestone- When did your child sit independently?*

Between 5- 9 monthsAfter 9 monthsStill unable to sit independentlyUnable to recall
Motor Development Milestone- When did your child start to crawl?*

Between 6- 9 monthsAfter 9 monthsDid not crawlUnable to recall
Motor Development Milestone- When did your child start walking (first steps)?*

Before 11 monthsBetween 11-15 monthsAfter 15 monthsStill unable to walk independentlyUnable to recall
Interventions your child has received or is receiving*

PhysiotherapyOccupational TherapyABA TherapyEIPIC / Early InterventionEducational Therapy / Learning SupportDyslexia Support (DAS or Similar)NoneOther
If other, please list the concern below.
Speech- Language History
What is your primary concern regarding your child's speech/language?*

Early Communication ChallengesArticulation / SpeechLanguageFluency / StutteringOtherNone of these
If other, please list the concern below.
Do you have concerns about your child's hearing*

Yes - has a hearing lossYes - does not seem to respond to name / soundsNo - tested at birth and no issue raised / no concernNot sure
When did your child say his/her first word?*

Between 10- 15 monthsBetween 16 - 18 monthsBetween 19-24 monthsAfter 24 monthsMy child is not speaking yet
Approximately how many total words does the child use? (For children aged under 2 years old)
How well can your child understand instructions?*

Understands only when I point / gestureOnly understands instructions within the home environmentUnderstands most things children his / her age understandNot sure
How well can your child express him/herself?*

Not able to talk yetGenerally 1-2 word outputSpeaks in short sentencesSpeaks in sentencesI am concerned how he / she produces sentencesAble to express him/herself like most children of the same ageNot sure
How clear is your child's speech?*

Unclear to family, school or othersSome sounds are still not produced wellNo concerns about speech soundsNot sure
Has your child received speech therapy before this or is your child receiving speech therapy?*

YesNo
Please provide information on speech therapy received.
Has your child started preschool / kindergarten / school?

YesNo
Do teachers have concerns about your child?

YesNo
Please provide information on the teacher's concerns.
Detail your concerns
Let us know your specific concerns about your child's communication challenges.
This form is submitted by
Name of Parent / Guardian*
Name as per official Document
Our email:
example@example.com
Thank you for submitting the form
Should be Empty:

SPEECH MATTERS

New Client Registration

Client and Family Information

Medical History

Child Development History Information

Speech- Language History

Thank you for submitting the form