SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY CLINIC Parent/Caregiver Questionnaire Please fill out this form as fully and accurately as you can and mail to the Clinic. The more detailed and accurate the information you give us, the better we will be able to evaluate the problem. If extra space is needed or if you wish to add information which might be helpful to us, please use the back of this form. All material and information will be kept in strict confidence by the clinic staff.

IDENTIFYING INFORMATION Date Client

Birthdate

Age

Sex

Address Street

City

State

Home Telephone Parent’s Name

Parent’s Name Age

Education (highest grade completed)

Age

Education (highest grade completed)

Occupation

Occupation

Employer

Employer

Business Phone

Business Phone

Physician

Referred by

Address

Address

Phone Person Filling Out Questionnaire (name/relation to client) DESCRIPTION OF PROBLEM In your own words, please describe as completely as possible your child's problem.

Zip

2 When did you first become concerned about the problem?

What is your opinion as to the cause of the problem?

PRENATAL AND BIRTH HISTORY During this pregnancy, did the mother experience any unusual illness, condition, or accident, such as German measles, Rh incompatibility, false labor, etc? If so, please describe

List medications taken by mother during pregnancy

Duration of Labor

Length of Pregnancy Hospital Name

Birth Weight ____________

Anesthetic used

Were there any problems with the delivery, such as breech birth, Cesarean, etc.? If so, please describe

Conditions immediately following birth: Did the infant have trouble starting to breathe? Did infant have sucking or swallowing difficulty? Other problems?

Was infant blue?

Jaundiced?

Feeding problems?

Seizures?

Was birth weight regained quickly?

DEVELOPMENTAL HISTORY Approximate age when child: Held up head alone

Sat alone without support

Pulled to standing position

Began to crawl

Walked without assistance

Fed self with spoon

Toilet trained:

Bladder: day

night

Bowel: day

night _________

Slept through the night: Could dress self, except for tying Does child seem to be Right-handed? ___________Left-handed?___________ Is the child awkward in using his/her hands?

Apgar rating ____ Scars or bruises? _____

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Does he/she? Open doorknobs?

Hold and scribble with a crayon?

Draw shapes/write letters?

Cut with scissors?

Does he/she have any difficulty tolerating: Being held?

Having face or mouth washed?

Having teeth brushed?

Having hair groomed?

Loud noises?

Certain specific sounds?

Does he/she fall or lose balance easily? Does he/she: Climb stairs using alternate feet? Push riding toy/pedal & ride tricycle or big wheel? Skip?

Hop on one foot?

Climb on high play equipment? SPEECH AND ORAL MOTOR HISTORY Language(s) spoken in the home Did he/she have any difficulty: Nursing or taking a bottle? Transitioning to baby food?

Eating any solid foods?

Drinking from a cup?

Drinking with a straw?

With reflux? Chewing, swallowing, or clearing food from mouth? Tolerating a variety of food textures and tastes? Does he/she: Drool? Chew on his/her fingers, toys, or blanket?

Suck thumb, fingers, or pacifier? Blow bubbles from a wand?

Snore?____________________ Appear to breathe mostly through the nose _________or mouth?_______________

Please list the approximate age at which your child began to: coo?

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Make babbling sounds (for example, "gaga")?

Use jargon (speech that is unintelligible however, has inflectional pattern similar to adult speech)?

________

Say his/her first word? What was it? Use rising inflection to ask questions (cookie?) Use 2-3 single words spontaneously besides "mama - dada" (not imitation)?

Use 2-word phrases to communicate (Me go, Mama eat?)? Have approximately a 50 word vocabulary? Use sentences? How does your child express his/her ideas? Describe:

Did speech learning ever seem to stop for a period? If so, did it correspond to any specific event (ear infections, stress, illness)?

Has the child ever spoken better than he/she does now?

Has there been a change in the child's speech in the last six months? If so, describe:

Can you understand everything child says? Y

N

Can others? Y

N ..........

Please explain Does your child seem to have any trouble: Understanding and following directions? Y

N

Understanding story sequences? Y

Does your child stutter: get stuck on words, repeat words, or restart sentences? Y Is your child's voice: hoarse?

too soft/loud?

too nasal?

N ...........

high or low-pitched? ...............

N ...........

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Does the child seem to be aware of a speech difficulty? If so, describe:

Has the child had a speech examination prior to this time? When, where and with whom? Has he/she ever received speech therapy? When, where, and with whom? Does he/she receive speech therapy at this time? Where and with whom? Are there any instances of hearing, speech-language, or learning disabilities in the family (siblings, parents, grandparents)? Please describe:

Please request that previous evaluation and progress reports be sent to us. HEALTH HISTORY Most recent exams (pediatrician, allergist, ENT, neurologist) Please describe:

Child's present weight

Height

When/where has his/her hearing been screened?

Pass/Fail

Any concerns? When/where has his/her vision been screened?

Pass/Fail

Any concerns? We would appreciate having test results or any information your physician might wish to send us. Check the illnesses, injuries, and any surgeries the child has had. Give child's age and severity of the illness. Please add others which the child has had, but which are not listed here.

OVER

6 Mild, Average, Severe

Age

Hospitalization

Date(s)

Illness/ Surgeries Ear infection High fevers Tonsillitis Bronchitis Allergies Seizures (convulsions) Chicken pox Injuries/accidents Tonsillectomy, Adenoidectomy Myringotomy/tubes inserted Other (please describe)

Were there noticeable changes in the child's speech immediately following any illness? If so, please describe:

PERSONAL AND FAMILY HISTORY Other children in the family: NAME

AGE/GRADE

ANY KNOWN PROBLEMS _________________________ __________________________ _________________________ ___________________________

Does your child's play involve: independent play (parallel play)? pretend play?(imagination) cooperative play? (games, shared play) How does your child get along with other children in the family? How does your child get along with friends/playmates? What are his/her favorite activities?

What type(s) of discipline work(s) best for this child?

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How long can he/she attend to TV

or listen to a story

Occupy him (her) self with toys Has he/she been seen by a psychologist/social worker/psychiatrist for behavior management? Who

When We would appreciate having any reports or relevant material sent to us.

SCHOOL HISTORY Grade

What school does he/she currently attend? Address Teacher At what age did the child start school?

Where?

What are the child's usual grades? Have teachers noted any areas of difficulty? Please describe:

How does he/she get along with others at school?

Does he/she receive any supportive services (tutoring, occupational therapy, counseling, other)? Please describe:

We have provided a school questionnaire for the teacher to complete. This will assist us in providing a comprehensive evaluation for your child. Please encourage the teacher to return it to us before the evaluation date.

For your protection, all such information can only be released when you request the person or institution doing the testing to send the information to this Clinic. Please list below any persons or places you have asked to send us information. Name

Name

Address

Address

City

State

Zip

City

State

Zip

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In addition, please list any professionals to whom you would like us to speak to prior to the evaluation for the purpose of receiving recent information Name

Phone #

Name

Phone #

I give my permission for the Clinic to speak with the above named professionals prior to my child’s evaluation. Signed Dated You will receive a copy of the Clinic report, after the fees are paid. To whom would you also like this report sent? (Physician(s), School, Insurance Company, etc.) Name

Name

Address

Address

City

State

Zip

City

I give my permission for these records on Signed

State

Zip

to be sent to the above listed professionals. Dated_________________________________________

Please do not release reports at this time. Signed

Dated

Additional Information If there is additional information which you feel will help us to understand your child and his problem better, please describe below. If this is not enough room please continue on the back of this page. Thank you. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

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The Atlanta Speech School does not discriminate on the basis of age, race, gender, religion, or national origin in providing services to the public or in employment practices. More importantly, please note that the School requests this information consistent with the commitment in our mission statement to be a resource for our community. At the Atlanta Speech School, we seek to provide services to students, clients, families, and schools that reflect the people and cultures that make up the fabric of our city. The information you supply below will assist us in our efforts to meet this goal. Please check one or more of the boxes below that best describe the applicant’s race and ethnicity. (Optional) Race:

Ethnicity: American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander White More than one race

Hispanic or Latino

Adapted from the U.S. Department of Education, Proposed Guidelines on Race and Ethnicity, 2006.