General Information

Child's Name:                Date:
Address:                              Phone:
City/State:        Zip Code:
Does the child live with both parents?  Yes:    No:
Mother's Maiden Name:         Age:
Mother's Occupation:     Business Phone:
Father's Name:                       Age:  
Father's Occupation:       Business Phone:
Referred By:                     Phone:
Address:
Pediatrician:              Phone:
Address:
Family Doctor:         Phone:
Address:
Brothers and Sisters (include name and ages):

What Languages does the child speak?:
What is child's primary language?:

What languages are spoken in the home?:
What is the primary language spoken?:

With whom does the child spend most of his or her time:

Describe the child's speech-language problem:

How does the child usually communicate (gestures, single words, short phrases, sentences):

When was the problem first noticed?  By whom?:

What do you think may have caused the problem?:

Has the problem changed since it was first noticed?:

Is the child aware of the problem?:  Yes:   No:
If yes, how does she feel about it?:

Have any other speech-language specialist seen the child?: Yes:   No:
Who and When:
What were their conclusions or suggestions:

Have any other specialist (physicians, psychologists, special education teachers, etc.) seen the child?:  Yes:   No:
If yes, indicate the type of specialist, when the child was seen, and the specialist's conclusion or suggestions.:

Are there any other speech, language, or hearing problems in your family?: Yes:   No:
If yes, please describe:

Prenatal and Birth History

Mother's general health during pregnancy (illness, accidents, medications, etc.):

Length of pregnancy:
Length of labor:
General condition:
Birth weight:

Check type of delivery:  Head first   Feet first   Breech   Caesarian
Were there any conditions that may have affected the pregnancy or birth?:

Medical History
Provide the approximate ages at which you suffered the following illnesses and conditions:

Allergies:        Asthma:               Chicken Pox:    

Colds:            Convulsions:                  Croup:

Dizziness:        Draining Ear:      Ear Infections:

Encephalitis:     German Measles:      Headaches:

High Fever:         Influenza:                 Mastoiditis:   

Measles:             Meningitis:                       Mumps: 

Pneumonia:          Seizures:                      Sinusitis:

Tinnitus:              Tonsillitis:                      Other:

Has the child had any surgeries?   Yes:   No:
If yes, what type and when (e.g. tonsillectomy, adenoidectomy, etc.)?:

Describe any major accidents or hospitalizations.:

Is the child taking any medications?  Yes   No

Has there been any negative reactions to medications?:  Yes   No
If yes, please identify.:

Developmental History

Provide the approximate age at which the child began to do the following activities:
Crawl:   Sit:   Stand:   Walk:   Feed Self :  Dress Self:   Use toilet:
Use single words (e.g. no, mom, doggie, etc.):
Combine words (e.g. me go, daddy shoe, etc.):
Name simple objects (e.g. dog, car, tree, etc.):
Use simple questions (e.g. Where is doggie? etc.):
Engage in conversation:

Does the child have difficulty walking, running, or participating in other activities which require small or large muscle coordination?:

Are there or have there been feeding problems (e.g. problems with sucking, swallowing, drooling, chewing, etc.)?:  Yes    No
If yes, describe:

Describe the child's response to sound (e.g., responds to all sounds, responds to loud sounds only, inconsistently responds to sounds, etc.):

Educational History

School:    Grade:
Teacher(s):

How is the child doing academically (or preacademically)?:

Does the child receive special services?:  Yes   No
If yes, Describe:

How does the child interact with others (e.g., shy, aggressive, uncooperative, etc.):

If enrolled for special education services, has an Individualized Education Plan (IEP) been developed?:  Yes  No

Provide any additional information that might be helpful in the evaluation or remediation of the child's problem.: 

Person completing form:
Relationship to child:
Date:

Signature: Submission of this form is deemed an electronic signature of the person completing this form.