Speech/Language Evaluation Parent Questionnaire

  • Speech/Language Evaluation Parent Questionnaire

    You have requested a speech and language evaluation for your child. In preparation for the examination, we need information to assist in planning for and conducting a complete evaluation. Please answer the questions as fully and accurately as possible. If you are not sure of a particular date, you can write the approximate date and put a question mark after that. Your family physician may be able to provide you with certain information, or consult the child’s baby book, if available. All the following information is for the confidential use of All in 1 SPOT with Theratalk. Please contact us if you have any questions. We look forward to working with you!

  • Family Information

  • Birth Date*
     - -

  • Parent/Caregiver #1

  • Format: (000) 000-0000.

  • Parent/Caregiver #2

  • Format: (000) 000-0000.
  • Does your child currently receive services through Early Intervention or the Department of Education?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Martial status of Parents*
  • Other children in family?*

  • REASON FOR REFERRAL

  • BIRTH AND DEVELOPMENTAL HISTORY

  • During this pregnancy, did the mother experience any unusual illness, condition or accident, such as German measles, false labor, RH incompatibility?*
  • Type of Delivery*
  • Any medication taken during pregnancy*
  • Significant birth history/unusual condition at or immediately after birth?*
  • Did the infant have feeding problems? Seizures?*

  • DEVELOPMENTAL MILESTONES

  • Does the child fall or lose balance easily?*
  • Does the child seem awkward or uncoordinated?*

  • MEDICAL/SOCIAL/EMOTIONAL HISTORY

  • Has child had illnesses, accidents or operations?*
  • Is there a history of middle ear infections?*
  • Does the child have any allergies? Asthma?*
  • Is the child taking any medication at the present time?*
  • Has the child been seen by any other doctor other than his/her regular doctor?*
  • Is there any history or neurological, hearing, psychological or hereditary problems in the immediate family or parents’ families?*
  • Is the child “nervous”?*
  • Has s/he been harder to manage than other children?*
  • Were grades repeated?*
  • Has s/he ever been evaluated in school?*
  • Regular or special education?*
  • How is his/her reading ability?*
  • Does s/he receive any special services in school? (e.g., reading, speech)*
  • Does child separate from parent?*
  • Does the child have good eye contact?*

  • AUDIOLOGICAL

  • Has an audiological evaluation been conducted?*

  • FEEDING ISSUES

  • Does the child drink using a cup?*
  • Does the child drink using a straw?*
  • Does the child feed him/herself?*
  • Does the child have difficulty chewing or swallowing?*

  • SPEECH &LANGUAGE HISTORY

  • Does the child follow commands?*
  • Does the child point and gesture?*
  • Does the child identify body parts?*
  • Does the child identify shapes?*
  • Does the child identify colors?*
  • Does the child identify familiar objects?*
  • Did s/he produce one or two words and then after a long time produce others?*
  • Did s/he keep adding words once s/he started to talk?*
  • Does the child imitate speech?*
  • Does the child answer “wh” or yes/no questions?*
  • Does the child label body parts, familiar objects?*
  • Does the child sing songs, rhymes, and produce his/her ABC’s?*
  • My child talks in...*
  • Did speech-language learning ever seem to stop for a period?*
  • Has s/he ever talked better than s/he does now?*
  • Does s/he seem to be aware of his/her speech difference?*
  • Is the child teased about his communication skills by others?*
  • Does the child have difficulty understanding speech or following instructions?*
  • Has the child had a prior speech, hearing, or psychological examination?*
  • Has the child had prior speech, hearing, or psychological therapy?*
  • Would you like a copy of this form?*

  • All information will be held in strict confidence and not released to any person(s) without explicit authorization nor shared with any unauthorized person.
    All in 1 SPOT with TheraTalk prohibits discrimination on the basis of race, religion, color, national or ethnic origin, age, sex, sexual orientation, marital status, or disability.


    EVERY CHILD DESERVES A VOICE. WE ARE HERE TO HELP YOU AND YOUR CHILD EVERY STEP OF THE WAY!


    Updated September 2023

  • Should be Empty: