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- Date of Birth*
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- Child lives with:*
- Do any close family members have a history of the following:
- Is any other language other than English spoken in the home?*
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- Was your child born premature?*
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- Was there anything unusual about the pregnancy or delivery? (e.g., hospital or NICU stay, medical procedures or surgeries, drug/alcohol use, etc.)*
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- Are the child's immunizations up-to-date?*
- Check all that apply:
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- Date of last hearing screening*
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- Date of last vision screening*
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- Check all that apply*
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- Do you consider any physical or fine motor abilities to be delayed or impaired? *
- Check all that apply:*
- Has your child been diagnosed with a developmental disability or behavioral disorder?*
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- Does your child attend school or daycare?*
- Does your child have an active IFSP (Individualized Family Service Plan) or IEP (Individualized Education Plan)?*
- Does your child have an active 504 plan?*
- Does your child receive any other therapies?*
- Has your child ever received a speech/language evaluation?*
- Has your child received speech/language therapy previously?*
- Is your child reading?*
- Did your child have or is your child having a difficult time learning to read?
- Does he/she reverse certain letters? (e.g., b/d reversal)
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- Was your child a quiet infant (limited vocalizations/babbling)?*
- Did your child produce any consonant sounds in babbling by 12 months of age? (e.g., "mmm," "dah," etc.)*
- Did your child produce consonant + vowel syllables by 18 months of age? (e.g., "doo," "buh," "no," etc.)*
- Did/does your child produce /k/ or /g/ sounds in their babbling? (e.g., "goo," "gah," "kah", etc.)*
- Did/does your child have 5 or more consonant sounds at 2-years-old?*
- Does your child have difficulty producing certain speech sounds?*
- Did/does your child prefer to use /m/, /p/, or /b/ sounds over others?*
- Does your child prefer to communicate with:*
- Does your child follow simple directions? (e.g, "sit down," "bring me the ball," etc.)*
- Does your child follow complex or multistep directions? (e.g., "before you sit down, bring me the ball," "put on your shirt and then your pants," etc.)*
- Does your child appear to understand what you are saying?*
- Does your child identify objects and actions easily?*
- Does your child respond correctly to yes/no questions?*
- Is your child's speech easily understood by others?*
- Does your child talk abnormally soft or seem to run out of air when talking?*
- Is your child aware of or frustrated by any speech or communication difficulties?*
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- Should be Empty: