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
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
EnglishMandarin / ChineseMalay (Bahasa Melayu / IndonesiaTamil / HindiOther
Speech / LanguageCommunicationFeeding /Swallowing difficultiesVoiceOther
If other, please fill in the primary reason for the appointment.
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.
37-40 weeks30-36 weeks25-29 weeks25 < weeks
Natural Birth / VaginalInducedAssisted (Forceps / Vacuum)C-Section
JaundiceProlonged Stay at NICULow birth weightBreathing DifficultiesSucking/Swallowing difficultiesInfection of baby or motherComplications at BirthHeart/CardiovascularLow APGAR SCOREHypoxia / Low Oxygen LevelsNone of theseOther
AsthmaCancerGenetic DisordersDiabetesMeningitisPhysical ImpairmentBrain InjuryHearing LossEar InfectionsVision lossStrokeCerebral PalsyNone of these
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.
Between 5- 9 monthsAfter 9 monthsStill unable to sit independentlyUnable to recall
Between 6- 9 monthsAfter 9 monthsDid not crawlUnable to recall
Before 11 monthsBetween 11-15 monthsAfter 15 monthsStill unable to walk independentlyUnable to recall
PhysiotherapyOccupational TherapyABA TherapyEIPIC / Early InterventionEducational Therapy / Learning SupportDyslexia Support (DAS or Similar)NoneOther
If other, please list the concern below.
Speech- Language History
Early Communication ChallengesArticulation / SpeechLanguageFluency / StutteringOtherNone of these
If other, please list the concern below.
Yes - has a hearing lossYes - does not seem to respond to name / soundsNo - tested at birth and no issue raised / no concernNot sure
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)
Understands only when I point / gestureOnly understands instructions within the home environmentUnderstands most things children his / her age understandNot sure
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
Unclear to family, school or othersSome sounds are still not produced wellNo concerns about speech soundsNot sure
YesNo
Please provide information on speech therapy received.
YesNo
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