Intake Form

Speech and Language

 
 
Patient Name *
Patient Name
Date of Birth *
Date of Birth
Parent/Guardian Name *
Parent/Guardian Name
Cell Phone *
Cell Phone
Home Phone
Home Phone
Background Information
Length of pregnancy: *
Type of Delivery: *
Did/Does your Child have Difficulty:
Developmental History
Present level of activity:
Walk
Babbling
Sentences
Holds Own Bottle
Cup Drinking
Finger Feeds
Crawling
Running
First Words
Dressing
Utensil Use
Straw Use
Hand Dominance
Behavioral Concerns:
Speech-Language Development
A quiet baby? *
A frequent crier? *
Irritable? *
Visually alert and attentive?
Auditorily alert and attentive?
Babble
Imitate speech sounds
Say two or more words
Understand speech sounds
Say first words
Did you child began to babble and stop?
At present, does your child:
Have understandable speech? *
Have a loud voice? *
Have a monotone voice? *
Have a horse voice? *
Have a stuttering problem? *
Respond to sound? *
Respond to loud sounds only?
Seem to willingly ignore sounds? *
Medical History
Educational Background
Address
Address
Phone
Phone