Child's Name:
*
First Name
Last Name
D.O.B
*
-
Month
-
Day
Year
Date
Parent's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Patient's Doctor Information
*
Referred by:
Teacher's Name:
*
School
*
Grade
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Other
Who does the child live with?
*
Both parents
Adoptive parents
Parent and Step parent
Foster Parents
One parent
Other
Family History: Please list if patient has siblings and their age:
*
Please list Siblings, if any, and age
Is there a family history of:
*
Speech/Language Difficulties
Hearing Impairment/Deafness
Learning Difficulties
Developmental Difficulties
None
If you responded "yes" to any of the above, please describe:
Statement of the problem: Describe in your own words what problem your child is having:
*
List any other concerns you have regarding your child's development:
Does you child have a formal diagnosis:
*
Yes
No
Not sure
If yes, what is it? When was it made & By whom?
Pregnancy/Birth History: Was Prenatal Care provided?
*
Yes
No
Not sure
Pregnancy was (Check One):
*
Normal
Complicated
If complicated, please elaborate below:
Spotting
High Blood Pressure
Diabetes
Smoking
Pre-Existing Condition
Fever
RH Incompatibility
Medications
Alcohol/Drug
Other
Birth: Term of Pregnancy
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Full or Premature
Delivery:
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Vaginal
Cesarean
Presentation:
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Breech
Head Down
Labor:
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Induced
Natural
Length of Labor:
*
Child's Birth Weight:
*
Special Considerations:
*
Cord around neck
Meconlum Birth
Jaundiced
Twin
Other
Incubation Time:
Medication:
Length of Child's Hospital stay:
Complications at Birth? Explain:
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Medical Information: Illnesses, Chronic Medical conditions and Diagnoses Include:
Hospitalizations and Surgeries:
Please include Date it occured, The reason, and Location
Has your child had any of the following?
*
Adenoidectomy
Allergies
Breathing Difficulties
Chicken Pox
Frequent Colds
Frequenr Ear Infections
Ear (PE) Tubes
High Fever
Head Injury
Sleeping Difficulties
Thumb/ Finger sucking
Tonsillectomy
Vision Problems
None
Please list approximate dates of when and any additional details:
Immunizations:
*
Current
Noncurrent
Non vaccinating
Specialist(s) Seen(Neurology, ENT, Orthopedic, GI, etc.):
Allergies:
Current Medications and Dosage:
Vision: (note if formal screening done, surgery done. corrective lenses used):
Dental: (note if teeth are present, any abnormalities or overbites)
Hearing: (note if ear infections are frequent, tube placement or hearing tests performed):
My child has had 3 or more ear infections between birth and 12 months of age
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Yes
No
Not sure
My child has had at least one ear infection which lasted more than three months
*
Yes
No
Not sure
My child has been evaluated by an audiologist who determined that his/her hearing is within normal limits.
*
Yes
No
Not sure
If yes, list Date of screening:
I suggest my child has a hearing problem
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Yes
No
Not sure
My child prefers one ear over the other
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Yes
No
Not sure
If yes, which ear?
*
Left
Right
Not sure
My child has had tubes in his/her ears.
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Yes
No
Not sure
If yes, When:
My child has hearing aids.
*
Yes
No
If yes, what type and for how long?:
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Oral Motor & Feeding History: Has you child experienced feeding/eating difficulties(e.g. biting, swallowing, and chewing)?
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Yes
No
Not sure
If yes, please explain:
Was your child breast-fed or bottle fed:
*
Breast-fed
Bottle-fed
Both
Does your child eat by one's self using utensils?
*
Yes
No
Not sure
Does your child drool?
*
Yes
No
Not sure
Does your child out toys in their mouth?
*
Yes
No
Not sure
If yes, please explain:
Does your child have food allergies:
*
Yes
No
If yes, please explain:
Does your child have food preferences/aversions?
*
Yes
No
If yes, please explain:
Does your child have a history of feeding problems?
*
Yes
No
Not sure
If yes, check all that apply:
Choking
Poor Nursing
Difficulty Biting
Difficulty Chewing
Overstuffing Mouth
Difficulty Swallowing
Is your child a messy or picky eater?
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Messy
Picky
Both
Neither
Please list their favorite foods:
*
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Speech, Language and Hearing Development: Did your child make babbling or cooing sounds during he first 6 months of life?
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Yes
No
At what age did your child say his or her first word?
*
What were your child's first words?
*
Did you child keep adding words once he/she started to talk?
*
Yes
No
If no, please explain:
At what age did your child begin using 2 and 3 word sentences?
*
Did speech learning ever seem to stop for a period of time?
*
Yes
No
If yes, please explain:
Does you child talk:
*
A lot
Occasionally
Never
Does your child prefer to:
*
Talk
Gesture
Talk and Gesture
Does your child most frequently use:
*
Sounds
Single words
2-word sentences
3-word sentences
More than 3 word sentences
Please list examples;
Does your child make sounds incorrectly?
*
Yes
No
If yes, Which ones?
Does your child hesitate, "get stuck", repeat or stutter on sounds or words?
*
Yes
No
If yes, please describe:
Please describe any recent changes in your child's speech if any:
Can your child tell a simple story?
*
Yes
No
How well can he/she be understood by the following individuals? Parents:
*
All the time
Most of the time
Some of the time
Rarely
How well can he/she be understood by the following individuals? Siblings:
*
All the time
Most of the time
Some of the time
Rarely
How well can he/she be understood by the following individuals? Teachers:
*
All the time
Most of the time
Some of the time
Rarely
How well can he/she be understood by the following individuals? Friends:
*
Allt he time
Most of the time
Some of the time
Rarely
How well can he/she be understood by the following individuals? Strangers:
*
All the time
Most of the time
Some of the time
Rarely
Please list any additional comments:
Does your child consistently answer to his/her name?
*
Yes
No
Does your child make appropriate eye contact with adults?
*
Yes
No
Does your child make appropriate eye contact with other children?
*
Yes
No
Does your child identify simple objects?
*
Yes
No
Does your child follow simple commands?
*
Yes
No
Please describe/ Give examples:
Does your child ever have trouble remembering what you have told him or her?
*
Yes
No
If yes, please explain:
Does your child enjoy looking at books?
*
Yes
No
How often do you read to your child?
*
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Sensory & Motor Development: Does your child have any difficulty walking, running, sitting or other large motor skills?
*
Yes
No
Not sure
If yes, Please describe:
Does you child tippy-toe walk?
*
Yes
No
Not sure
Is your child clumsy or does he/she fall easily?
*
Yes
No
Not sure
Does your child have low body tone?
*
Yes
No
Not sure
Does your child have difficulty with fine motor skills such as stacking, cutting and handwriting?
*
Yes
No
Not sure
If yes, Please describe:
Motor milestone Development ages obtained:
Crawled:
*
Sat:
*
Stood:
*
Fed Self:
*
Type a question
*
Walked:
*
Fed Self:
*
Dressed Self:
*
Toileted:
*
1st Words:
*
Is your child sensitive to certain textures of food or clothing?
*
Yes
No
Not sure
If yes, Please describe:
Does you child dislike having substance on his/her hands such as glue or dirt?
*
Yes
No
Is your child oversensitive to being touched or dislike being touched?
*
Yes
No
If yes, please describe:
Does your child have gastrointestinal issues?
*
Yes
No
If yes, explain:
Check all that apply:
*
Child finger feeds
Uses a fork
Uses a spoon
Uses an open cup
Uses a straw
Is adult assistance needed with feeding?
*
Yes
No
If yes, explain:
Has he/she choked on solid foods?
*
Yes
No
Does your child cough on liquids?
*
Yes
No
Can your child chew well?
*
Yes
No
Does he/she drool?
*
Yes
No
If yes, when?:
Did your child use a pacifier?
*
Yes
No
If yes, age weaned from pacifier:
Does your child continue to mouth objects?
*
Yes
No
Did your child suck his/her thumb/fingers?
*
Yes
No
If yes, until when?
Does your child suck on his/her clothing/blanket/etc?
*
Yes
No
If yes, what?
Does your child resist tooth brushing?
*
Yes
No
Does he/she like taking a bath?
*
Yes
No
Does he/she like swings?
*
Yes
No
Does he/she like parties?
*
Yes
No
Does he/she like rough housing?
*
Yes
No
Your child prefers to play:
*
Alone
With other children
With older children
With younger children
With adults
Id your child overly sensitive to loud sounds?
*
Yes
No
Is your child overly sensitive to bright lights?
*
Yes
No
Is your child overly sensitive to tags on clothing?
*
Yes
No
Give ages at which the following firs occurred: Sat up:
*
Crawled:
*
Stood:
*
Walked:
*
Ran:
*
Bladder Trained:
*
Bowel Trained:
*
Night Trained:
*
Which hands does the child use more frequently?
*
Right
Left
No preference
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Behavior: Does your child typically display ant of the following behaviors? (check all that apply):
*
Reduced or lack of interaction with others
Tantrums
Passive in interactions
Difficulty staying on task
Difficulty finishing tasks
Sensitive
Very active
Underactive
Inattentive
Refuses to perform tasks
Angry/ acting out behavior
Frustrated
Shy
Education History: What does your child attend?
*
Daycare
Preschool
Kindergarten
Grade School
Name of School:
Grade/ Level:
In school, is he/she work typically:
Average
Below Average
Above Average
What are the child's best subjects?
Has he or she repeated a grade?
Yes
No
Is yes, which one(s)?
What is your impression of your child's learning abilities?
*
What is your impression of your child's social skills?
*
Does your child display any behavioral or attentional issues at school?
*
Describe any speech, language, hearing, OT, PT, Psychological, special education services, tutoring that the child is receiving/ has received.
*
Please sure to include type of therapy, Therapist, Frequency, Place, Group or Individual, and Duration.
Favorite Activities: Please list some of your child's favorite toys, games, hobbies, etc.
*
What do you consider to be your child's greatest strengths?
*
What other concerns do you have about your child?
*
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