Child Assessment Form
Child's Name
First Name
Last Name
Child's Date of Birth
/
Month
/
Day
Year
Date
Guardian's Phone Number
Please enter a valid phone number.
Guardian's Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Medical History:
Child's Current Medications
Allergies (Medications, Latex...etc)
Previous clip or release of tongue
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Month
-
Day
Year
Date
Has your child experienced any of the following?
Speech
Frustration with communication
Difficult to understand by parents
Difficult to understand by outsiders
% Percent of time you understand your child
Difficulty speaking fast
Difficulty getting words out
Trouble with sounds
Speech delay
Stuttering
Speech harder to understand in long sentences
Speech Therapy
Mumbling or speaking softly
"Baby Talk"
Other
Feeding
Frustration when eating
Difficulty transitioning to solid foods
Slow eater (doesn't finish meals)
Small appetite / Trouble gaining weight
Grazes on food throughout the day
Packing food in cheeks like a chipmunk
Picky eater with textures
Choking or gagging on food
Spits out food
Won't try new foods
Other
If trouble with sounds, which sounds?
If in speech therapy, how long?
If picky with textures, which textures?
Nursing or Bottle-Feeding Issues as a Baby
Painful nursing or shallow latch
Poor weight gain
Reflux or spitting up
Unable to hold pacifier
Milk dribbled out of mouth / messy eater
Poor Supply
Nipple shield required for nursing
Clicking or smacking noise when eating
Cried a lot / colic as baby
Other
Sleep issues
Sleep in strange positions
Sleeps restlessly (moves a lot)
Wakes easily or often
Wets the bed
Wakes up tired and not refreshed
Grinds teeth while sleeping
Sleeps with mouth open
Snores while sleeping
Gasps for air or stops breathing (sleep apnea)
Other
If snores while sleeping, how often?
Other related issues
Neck or shoulder pain or tension
TMJ Pain, clicking, or popping
Headaches or migraines
Strong gag reflex
Mouth open / mouth breathing during the day
Tonsils or adenoids removed previously
Ear tubes previously / lots of ear infections
Reflux (medicated or not)
Hyperactivity / Inattention
Constipation
Other
Anything else we need to know?
Pediatrician
Speech Therapist
Who referred you to us?
Submit
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