Language
English (US)
Spanish (Latin America)
Pediatric Speech Intake Form
Please fill in the form below if the new patient is between the ages of 20 and younger.
Pediatric Patient Information
Please answer each question to the best of your knowledge.
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2024
2023
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Year
Date of Evaluation
*
-
Year
-
Month
Day
Date
Referred By:
*
First Name
Last Name
Pediatrician/Physician Phone Number
-
Area Code
Phone Number
Which location is the patient visiting today?
*
Uptown- 4219 Magnolia Street New Orleans
Elmwood- 5640 Jefferson Hwy Harahan
What is the email address of the provider completing this form?
*
example@example.com
Parent/ Guardian Name
*
First Name
Last Name
Parent's Email Address
Primary Language Spoken
*
English
Spanish
Vietnamese
Other
Patient Sex
*
Please Select
Male
Female
N/A
Primary Concern for Appointment
*
Hearing
Speech/Language
Both
Other
If Other, please type your reason for today's appointment below. If not applicable, please type N/A.
Medical History
Please complete each question to the best of your knowledge.
Please list Medical History/Symptoms
*
Is the patient currently taking any medication?
*
Yes
No
If yes, please list all medication below.
Does the patient's development seem normal? If yes, please type YES. If no, please list dates of occurrence and please explain why.
Has the patient ever received physical therapy? If no, please type NO. If yes, please list dates of enrollment and explain why.
Has the patient ever received physical therapy? If no, please type NO. If yes, please list dates of enrollment and explain why.
Does the patient have any allergies? If yes, please list all allergies below.
Speech- Language History
What is your primary concern regarding the patient's speech/language?
*
Early Language Delay
Articulation
Language/Literacy
Fluency
Other
None of these
If other, please list the concern below.
*
Does the patient's speech seem normal? If no, please explain why you do not believe the patient's speech is normal.
*
When did the patient say his/her first word?
*
12 months
24 months
Greater than 24 months
My child is not speaking at this time
Does the patient become frustrated when communicating? If yes, please explain.
Approximately how many total words does the patient use?
Is the child understood by most people?
Does the patient follow a typical diet? If no, please explain.
Does the patient have difficulty swallowing? If yes, please explain.
Academic History
If so, what school does the patient attend?
What grade is the patient currently in?
What is the patient's grade point average?
A
B
C
D
F
Other
Not Applicable
If yes, what type of assistance does the patient receive in school?
Is there anything else that you would like to tell us about the patient's speech and hearing?
Submit
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