Fields marked with * are mandatory
       
 
 

 
*Name  
*Date of Birth                                                                             Sex  
Mother's Name     Father's Name   

Referred By    Reason for Referral 

Family History
Brothers/Sisters Date of Birth       Sex Speech/Hearing/Medical Problems

Has any member of the patient’s family had?  Select Yes/No
Relationship to Patient
Speech or language problems?
Hearing problems?
Learning disability?
Cleft lip or palate
Mental retardation
Which languages are spoken in the home?
Which language is most commonly used by the patient?

 
Maternal, Birth and Early Developmental History
Mother’s health during pregnancy?
Complications during pregnancy?
Explain

How long was pregnancy? Full term Premature by  weeks
Labor and delivery: Normal  

Check if any of the following conditions were present at birth

Other: Check if any of the following conditions were present at birth:
(how long?)        
(how long?)   

            
Medical History
Has the patient’s health been
Explain?

Has Patient ever had (Select Yes/No)
Scarlet fever Pneumonia Frequent Headaches
Diphtheria Meningitis Diabetes
Sinus Tonsillectomy Epilepsy
Earaches Adenoidectom Poor Coordination
Chronic colds Encephalitis Cerebral palsy
Asthama Rheumatic fever Head Injury
Allergies 
Hospitalizations
Surgeries
Serious illnesses
What medications and dosage is the patient taking?
Has the patient’s vision been tested?     When?    By whom? 
What were the results?
Has the patient’s hearing been tested?     When?  By whom? 
What were the results?
                                                                                                                                                   
Developmental and Educational History

At what age did the patient do the following:
 Support head   Sit up    Crawl
 Stand    Walk   Feed self with hand 
 Bladder control   Bowel Control    Feed self with spoon  
 Babbling  Begin to say words  Put 2-3 words together 
 Talk in sentences
Does the patient have or do any of the following?
 Bed wetting    Nail trimming    Food fadisms 
 Sleeping problems  Temper tantrums  Abnormal aggressiveness
 Day dreaming    Mood swings  Poor concentration
 Hyperactivity

What school does the patient attend?
Grade     Teacher
Address Line1    
Street 
City 
State  
Zip   
Phone  #  - -                                          
How is the patient’s general school performance?
What is his/her best subject?              Most difficult subject
Reading level:   grade
Writing level: (check all that apply)                
                   
                                          
Has he/she ever been in a special education class?   Why?
Has he/she ever had help from a resource teacher? For what?
Has he/she ever been tested at school? Why? 
Results
 


Communication Concerns

What concerns you or the patient most about the patient’s communication (oral or written)?

Who first noticed the problem?        When?

Did the patient’s speech or language development seem to stop?

when?

Is the patient ever frustrated or embarrassed by his/her speech?  
Has there been a change in the patient’s speech in the past 6 months?

If yes, explain

What effects have been made to help the patient’s communication?
How is the patient at following directions?
Carrying on a conversation?
Being understood by the family?
Being understood by peers?
Being understood by teachers or boss?
Has the patient ever had speech therapy?  When?
Where? Results?
What problems other than speech does the patient have that concerns you?
What specific questions about the patient’s communication do you want answered?


Fine Motor and Self Help Skills

What is the patient’s hand preference? 

Which self help skills has the patient mastered? (check all that apply)
Has the patient ever been tested or treated by an Occupational Therapist?
When?  Results



Word Verification
Type the characters you see in the picture below:


Note : This information is confidential and intended only for use by Speech Pathways, P.C. personnel.
                                                                                                                                            		  
                                                                                                                                                                                                                    
                                                                                                                                                                               
   

 
 

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