TLS Speech &Language Intake Form

Speech & Language History Form Thank you for taking a few minutes to complete this history form. All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Child's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Child's Birth Date*

MonthDayYear
Parent Name*

First NameLast Name
Parent's Email*
Parent Cell Phone*
Parent Occupation*
Parent #2 Name

First NameLast Name
Parent E-mail
Parent Cell Phone
Parent Occupation
Marital Status:
Who referred you?*
Child's Allergies *
Child's Medications*
Why are you seeking a speech and/or language evaluation?*
Pregnancy & Birth Information
Pregnancy*

NormalComplications
Pregnancy Complications please explain:*
Length of pregnancy*
Delivery Was:*
Birth weigh: lbs oz*
Please explain any complication during delivery or immediately following birth:*
Medical Information
List any Educational/Neurological/ Psychological evaluations - when, where (professional) and findings*
List any PHYSICAL THERAPY or OCCUPATIONAL THERAPY evaluations - when, where (professional) and findings*
List any AUDIOLOGICAL or HEARING testing - when, where and findings*
Please check if your child has experienced any of the following:*

auto-immune diseasemigranesseizuresconcussionnoneOther
List illnesses, accidents or operations your child has had:*
Developmental Motor History

At what age ( in months) did your child first?
Roll over
Sit Up
Crawl
Stand alone
Walk
Smile
Dress Self
Toilet trained
Developmental Speech History

At what age ( in months) did your child first?
Babble*
Say 1st word*
Combined 2 words*
Produce sentences*
Currently, does your child (select all that apply)

Responds to his/her name?Point to objects when asked?Follow simple directions (e.g.get your shoes?)Point to common objects uponrequest?Respond correctly to yes / noquestions?
Feeding
Please select all that apply to your child during mealtime?

Choke or cough on foods or liquidPocketing food in mouthGaggingRefluxSpits food outDifficulty swallowingWet/gurgly voice qualityDiet limited to less than 10 foodsPicky eaterSignificantly aversive to specific texturesHas a tantrum when new foods are presentedRefuse new foodsRefuse to eat with the familyDiet less than 20 foodsArguments about food occur regularlyMy child seems to have no appetiteIt is a struggle to get my child to eatVomitingEats too fastDroolingLoses food or fluid while eatingDifficulty sucking the bottleOther
How was your child fed during infancy? Breast? Bottle? How long did your child breast and/or bottle feed? If fed by abottle, what formula? Any difficulties with breast or bottle feeding?
Previous history? :

Tube fedRefluxDifficulty chewing or swallowingDifficulty sucking the bottle or breastFailure to thrive or gain weightChoking on food or liquidsFeeding TherapyNone of the above
Is there additional relevant information or concerns we should know about your child's feeding?*
Play Skills / Social Skills
Check all that apply regarding your child's play skills:

Bangs items / headMouths objectsStacks blocksManipulates knobs/buttonsFeeds doll, stuffed animalsMoves toy car with the appropriate sound of a vehicleCombines ideas (e.g. drives car and crashes it)Plays out scenarios, 3-4 steps (e.g. set table, pretends to cook food, eats food).
If applicable : check all that apply:

Difficulty meeting and making friendsDifficulty keeping friendsDifficulty being assertivePoor self-esteemTrouble with stress managementTrouble with anger managementDifficulty initiating and maintaining appropriate communicationDifficulty with voice modulation and pragmatics (using and understanding language within social contexts)Exhibits socially unacceptable behaviorsDifficulty with picking up nonverbal social cue
Home Environment
Who lives at home with your child? (Name, Ages, Relationship to child):
Schedule: Please describe a 24-hour time period for your child (i.e. from the time they wake up, until they go to bed ,including daily routines, how they sleep):
Primary language(s) spoken at home?*
Educational Information
Child's School Name & Grade*
What concerns do you have about your child's speech and language?*
Describe your child's personality listing his/her strengths and weaknesses.*
What activities and hobbies does your child enjoy?*
Do most people understand your child?*

OftenSometimesNo, rarelyOther
My child has difficulty:
Check all that apply

remembering namesremembering vocabularyfollowing directionsunderstanding sarcasmunderstanding jokesexplaining a movie, story or past eventreading for pleasurecompleting homework without difficultyparticipating in family and classroom activitiescommunicating independently with unfamiliar peoplecommunicating without frustrationspeaking without stutteringsaying specific sounds
Does anyone in your family have similar speech or language difficulties?*
What else would you like me to know about your child?*