Download Today`s Date: ______ CLIENT INFORMATION Name: Age: ____

Today’s Date: _________
CLIENT INFORMATION
Name: __________________________________ Age: __________
Birth date: ______________
Referred by:_________________________________________________________________________
FAMILY BACKGROUND
Mother’s Name: _____________________________________________ Age: ___________
Occupation:__________________________________________________________________
Marital Status:  Single  Widowed Divorced  Married  Separated
History of Speech or Language Problems?
 Yes
 No
If “Yes” please explain:_________________________________________________________
____________________________________________________________________________
Father’s Name: _____________________________________________
Age: ___________
Occupation:__________________________________________________________________
Marital Status:  Single Widowed  Divorced  Married  Separated
History of Speech or Language Problems?
 Yes
 No
If “Yes” please explain: ________________________________________________________
____________________________________________________________________________
Brothers and Sisters:
Name
Age
Speech or Medical Problems?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Who is currently living in the home with your child?
 Biological Mother  Biological Father  Adoptive Parents
 Brothers  Sisters
 Other (please specify)
____________________________________________________________________________
____________________________________________________________________________
Is there a family history of any of the following?
 Hearing Loss
 Speech Problem
 Learning Disability
 Autism
 Cleft Palate
 Seizure Disorder Alcoholism
 Drug Use  Stuttering
If “Yes” please explain:_________________________________________________________
____________________________________________________________________________
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Is any language other than English spoken in the home?  Yes
 NoIf “Yes”, please list
the language(s)? ______________________________________________
What is the primary language spoken at home? _____________________________________
Have there been any major changes in the family during the last year?
If yes, please specify i.e. changes of address, parent separation/divorce, accident,
illness/death, births, adoptions, marriage, etc.
____________________________________________________________________________
____________________________________________________________________________
STATEMENT OF THE PROBLEM
Describe in your own words the speech or language problem you feel your child is
experiencing._________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
When did you first notice the problem? ____________________________________________
What is your child’s awareness of/reaction to the problem? ____________________________
____________________________________________________________________________
How do you and other family members react to this problem? _________________________
____________________________________________________________________________
Has your child received any previous treatment for this problem?  Yes No
If “Yes”, where and from whom?
____________________________________________________________________________
____________________________________________________________________________
What information do you hope to gain from this evaluation and what specific questions or
areas do you wish us to address?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
PRENATAL AND BIRTH HISTORY
Check any of the factors below that apply:
During Pregnancy:  Excessive vomiting  RH Incompatibility
 Drug use
 Alcohol use  Hemorrhaging  Smoking
 Illnesses
 High Blood Pressure
 Trauma or injuries
 X-ray Treatments
Other _____________________
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Labor and Delivery (Please check any that apply):
 Full Term  Breeched Presentation  Premature: ____weeks early
Birth Weight: ________________
 Normal Delivery  Induced Labor  Cesarean  Prolonged Labor
Conditions affecting child
 Difficulty Breathing
 Seizures
 Jaundice
 Forceps
after Birth (Please check any that apply):
 Difficulty Sucking
 Difficulty Feeding
 Birth Defect
 Extended Hospital Stay
 Infections
Other ______________
MEDICAL HISTORY
Has your child ever had the following?
 Ear Infection
 Tubes Inserted
 Head Injury
 Encephalitis
 Other________________________
 Allergies
 Meningitis
 Asthma
 Seizures
Please list any medications your child is currently taking and why: ______________________
____________________________________________________________________________
____________________________________________________________________________
Does your child wear glasses?  Yes  No
Hearing Aides?  Yes  No
List any frequently occurring medical problems your child has.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
List any illnesses, injuries, or hospitalizations. Please include year.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you suspect your child has a hearing loss?
 Yes  No
If “yes” what behaviors led you to suspect this? _____________________________________
____________________________________________________________________________
____________________________________________________________________________
Has your child’s hearing ever been tested?
 Yes  No
Location:____________________________
Date ____________________________
Results: _____________________________________________________________________
Recommendations: ____________________________________________________________
____________________________________________________________________________
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Has your child received services from any of the following professionals?  Yes
If so, please indicate from whom, where and when:
 No
Speech-Language Pathologist:____________________________________________________
Audiologist:___________________________________________________________________
Psychologist/Psychiatrist:________________________________________________________
Physical/Occupational Therapist:__________________________________________________
Ear, Nose, Throat Doctor: _______________________________________________________
Neurologist: __________________________________________________________________
Opthalmologist/Optometrist:_____________________________________________________
Other: _______________________________________________________________________
Please provide a copy of any evaluation report received within the last 3 years.
MOTOR DEVELOPMENT
At approximately what age did your child achieve the following motor milestones?
____________Sitting alone
__________Crawling
__________Standing alone
____________Walking alone
__________Feeding self __________Potty training
SPEECH AND LANGUAGE DEVELOPMENT
Indicate at what age your child demonstrated the following:
_________ Babbling
_________Jargon (talking in own language)
_________Phrases
_________Short sentences
_______ Single words
What is the primary method your child uses for letting you know what he/she wants? Some of
these may not be relevant for your child’ current age. (please check any that apply):
Looking at objects
Pointing at objects
Gestures and signs
Crying
Vocalizing
Leading you to desired object
Single words
2-3 Word combinations
Sentences
Which of the following describes your child’s speech? (Please give examples)
 Easy to understand: _________________________________________________________
 Difficult for mother to understand:______________________________________________
 Difficult for others to understand:_______________________________________________
 Almost never understood by others:_____________________________________________
 Different than other children of the same age:___________________________________
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If your child does not use words, please describe how s/he communicates: _______________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Which of the following statements best describes your child’s reaction to his/her speech?:
 Is easily frustrated when not understood
 Does not seem aware of speech/communication problem
 Has been teased about his/her speech
 Tries to say sounds or words more clearly when asked
 Is successful in saying sounds or words more clearly when he/she tries
Does your child have difficulty pronouncing certain sounds?  YesNo
If “Yes”, which ones?___________________________________________________________
____________________________________________________________________________
Does your child hesitate and/or repeat sounds or words?
 Yes  No
Does your child “get stuck” when attempting to say a word?  Yes
 No
If so, please mark any behaviors that you have observed:
Repeats individual sounds or syllables (ex. B-b-baby)
Repeats single words (ex. My, my, my)
Prolongs sounds (ex. Mmmmmmy)
Repeats phrases (ex. Can I, can I, can I go?)
Shows physical or emotional tension
Blocks the sound at the beginning or middle of the word when trying to speak
Is there a family history of stuttering that you are aware of? Please explain. ______________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Does your child’s voice frequently sound rough or hoarse? If yes please explain.
____________________________________________________________________________
____________________________________________________________________________
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Do you question your child’s ability to understand directions or conversations? Yes  No
Which of the following do you think your child understands? Some of these may not be
relevant for your child’ current age. (Please check any that apply)
His/her own name
Simple directions
Names of body parts
Complex directions
Family names
Names of objects
Conversational speech
Do you find it necessary to use gestures to help your child understand what you want? Please
describe: ____________________________________________________________________
____________________________________________________________________________
PLAY BEHAVIORS
What is the average length of time your child can stay playing at one activity?_____________
____________________________________________________________________________
What activities seem to hold your child’s attention for the longest period of time? __________
____________________________________________________________________________
SOCIAL AND EMOTIONAL BEHAVIOR
Check the behaviors that describe your
Overly quiet
Overly active
Very shy
Perfectionistic
Plays well with other children
child:
Excessive tantrums
Destructive
Friendly/outgoing
Imaginative
Difficulty separating from parent
Please indicate how you feel about your child’s behavior/development in the following areas:
Average/Good
Below average
If below, please explain
Balance
Gross Motor
Fine Motor
Chewing/swallowing
Eating
Social Interaction
Vision
Self help skills
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EDUCATIONAL HISTORY
Does your child attend:
Preschool Day care Public school
Private school
Home schooled
Name of school: ___________________ Address: ___________________________
Grade/Level: ________
Teacher: ______________________________________
Name of child care provider: ____________________________________________
Address: ____________________________________________________________
Is your child on an Individualized Education or Family Service Plan (IEP or IFSP)? Yes No
If so, describe what needs are addressed by the plan i.e. social, communication, OT, PT:
Please attach plan if available!
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If not attached, please have your child’s school send a copy to the address listed on the front
of this questionnaire.
Does your child enjoy school/child care?  Yes No
Please comment:______________________________________________________________
____________________________________________________________________________
Are there any concerns reported by the teacher/care provider?  Yes No
If so, please describe:__________________________________________________________
____________________________________________________________________________
Is your child having any difficulty with:
 Learning to read  Spelling Telling stories  Understanding emotions of others
Please describe how your child interacts with peers while at school/child care:_____________
____________________________________________________________________________
____________________________________________________________________________
Are there any additional concerns that you have?
____________________________________________________________________________
____________________________________________________________________________
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Please provide any additional information you feel might be helpful in evaluating your child:
____________________________________________________________________________
____________________________________________________________________________
To the best of my knowledge the information provided here is complete and factual.
___________________________________
Signature of person completing this form
_____________________
Relationship to client
_____________
Date
Thank you for your help. Your insights will enable us to do our best for you!!!
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