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Harry Jersig Center 411 S.W. 24th Street San Antonio, TX 78207 (210) 431-3938 CLEFT PALATE HISTORY FORM Child’s name: _______________________________________ Age:_________ DOB:___/____/____ Parent/guardian name:_________________________________________________________________ Address:________________________________ Gender:__________ City/Zip code:___________________________ Height: _____________ Weight:_____________ Today’s Date:__________ Referral by:__________________________________________ SS#:_____-______-___________ Insurance Co: _______________________________ Member ID: __________________________ Contact phone: ________________________ Email address:____________________________ Primary Care (Attending) Physician:_____________________________________________________ Address:__________________________________________Phone Number:______________________ History of Problem Please check any of the following that applies to your child: ____ Cleft lip (unilateral) Which side? ______________ ____ Cleft lip (bilateral) ____ Cleft palate (unilateral) Which side? ______________ ____Cleft palate (full length) ____ Cleft lip and palate A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University Which of the following cleft/palate symptom(s) applies to your child? Feeding/eating problems Misaligned teeth Poor growth Change in nose shape Failure to gain weight Language Delay Recurrent ear infections Speech sound difficluties Hypernasal voice quality Avoids social situations Flow of liquids through nasal passages during feeding/drinking When was the cleft lip/palate first noticed? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Who first noticed the problem? _____________________________________________________________________________________ Was surgery performed? Yes No By whom? At approximately what age was your child? ____________________________________________________________________________________ ____________________________________________________________________________________ Have any further surgeries been performed or recommended for your child? When and by whom? ____________________________________________________________________________________ ____________________________________________________________________________________ Was there follow-up with specialists after surgery? ____ ENT number of visits: _______ ____ speech therapist number of visits:_______ ____ orthodontist number of visits: _______ ____ plastic surgeon number of visits: _______ ____other number of visits: _______ specialty: ______________________________ A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University (Circle one) Symptoms are getting : worse better staying the same If worse or the same, please identify the persisting symptoms: _____Dental cavities _____Displaced teeth _____Hearing loss _____Lip deformities _____Nasal deformities _____Recurrent ear infections _____Speech difficulties _____Hypernasal voice quality _____Nasal regurgitation of food or drink _____Other:_________________________________________________________________________ What is your child’s reaction to the cleft lip/palate? _____________________________________________________________________________________ _____________________________________________________________________________________ Has there been any significant change in the last six months? ___________________ If so, what? ______________________________________________________________________________ How well is your child understood by : (i.e., what percentage of the time) Mom:______________ Dad:______________ Younger siblings:_____________ Older siblings:_________ Other Children:_________________ Extended family:________________ Unfamiliar adults:__________ Describe what it is like to have a conversation with your child: _____________________________________________________________________________________ _____________________________________________________________________________________ Any previous assessments? Y N Where? __________________________________________________ By whom?_____________________________What kind?____________________________________ Which tests were given?________________________________________________________________ What were the results?_________________________________________________________________ Any previous speech therapy? Y N Where?___________________________ With whom? ____________________________________________________________________________________ A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University Related Medical and Developmental History How many pregnancies has the mother had?_______ Which pregnancy was this child?______ Mother’s age at the time of this pregnancy: _______ Has the mother had any miscarriages? ______ If yes, which pregnancy? ______ Stillbirths?______ If yes, which pregnancy?______ Did the mother have any of the following during this pregnancy? German measles_____ Toxemia______ Anemia______ Kidney infection______ Accidents/injuries (describe)______________________________________________________ _____________________________________________________________________________ Other maternal medical condition (describe) _________________________________________ What medical management (drugs during labor and delivery) did the mother receive? ____________________________________________________________________________________ ____________________________________________________________________________________ Did mother take prescription and/or nonprescription medication during this pregnancy? ____________ If yes, please list medications______________________________________________________ ____________________________________________________________________________________ Was your child full-term? ______ premature? _______ birth weight:______________ Length of hard labor: ______________ Was the delivery: Normal? ________ Cesarean? ________ Were forceps used?________ Breech? ________ Any birth injuries? ______________ (Circle one) Has there been any history of birth defects in your family? Yes No If yes please describe? With what family relation did it occur? ____________________________________________________________________________ ____________________________________________________________________________ A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University Did any other syndromes or illness co-occur with your child’s cleft lip/palate? If so, please describe. ____________________________________________________________________________ ____________________________________________________________________________ Does your child have any allergies, including any food allergies? If so what are they? ____________________________________________________________________________ ____________________________________________________________________________ (Circle one) Is your child taking any over the counter medications at this time? Yes No If yes, which ones and for what? _____________________________________________________________________________ Are immunizations current? Y N Current general health?__________________________________________________________ Age when child: (If you can’t remember specific time, please indicate if it occurred at the expected time or was delayed) sat up___________ crawled _____________ walked________________ toilet trained______________ dressed self ______________ tied shoes_______________ fed self independently________________ Attention span for self- directed activities:_________________________________________________ Does your child play with others? _______________________ Who?____________________________ Cry appropriately?___________________Laugh?________________Smile?______________________ Make wants known?_________________________ How?____________________________________ Does your child show unusual behavior (explain)? _________________________________________________________________________________ Speech and Language Language(s) spoken in the home:________________________________________________________ Age when child spoke first word:_______combined words:_______spoke in sentence:_____________ A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University Which sounds (if any) are incorrect? _____________________________________________________ Does your child have any difficulty understanding you (describe)? _____________________________________________________________________________________ _____________________________________________________________________________________ Does your child have any difficulty following directions (describe)? _____________________________________________________________________________________ _____________________________________________________________________________________ Any speech or hearing problems in the immediate or extended family (explain)? _____________________________________________________________________________________ _____________________________________________________________________________________ Social Development Names and ages of siblings: _____________________________________________________________________________________ _____________________________________________________________________________________ Other adults living in the home: _____________________________________________________________________________________ _____________________________________________________________________________________ Number of regular playmates: _______________ Ages:__________________ Genders:______________ How does your child handle frustration? ___________________________________________________ What motivates your child the most? ______________________________________________________ School History What school does your child attend: ______________________________________________________ What grade is your child in?_____________ How does your child’s teacher describe his/her performance? _____________________________________________________________________________________ Has the teacher expressed any concern? If so, what? __________________________________________ Is there anything else you would like us to know about your child? ______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ A Program Dedicated to the Evaluation, Diagnosis and Treatment of Language, Speech, Voice, Swallowing, Feeding, and Hearing Disorders of Children and Adults. Graduate Education and Clinical Service Programs in Audiology and Speech‐Language Pathology accredited by the Council of Academic Accreditation of the American Speech‐Language‐Hearing Association. An Equal Opportunity/Affirmative Action University
