Speech & Language Intake Form Patient Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Parent/Guardian Name * First Name Last Name Cell Phone * (###) ### #### Email Address * Home Phone (###) ### #### What languages are spoken in the home? * Who is the child’s primary caregiver during the day? * What language(s) do the primary caregivers speak to your child? BACKGROUND INFORMATION Maternal Age * Describe your primary concern(s) regarding your child: Number of previous pregnancies: Number of children: Ages: Length of pregnancy: * Full Term Premature Weeks Gestation: * Type of Delivery: Vaginal C-Section Breech Note any complications of labor & delivery (including medications): Birth Weight: Length of Hospital Stay: Did/Does your Child have Difficulty: Sucking? Swallowing? Chewing? Changing to Solid Foods? DEVELOPMENTAL HISTORY Present level of activity: Active Typical Low Arousal Developmental Milestones (give approximate age in months): Sat Alone: * Walking * (give approximate age in months) Babbling * (give approximate age in months) Sentences * (give approximate age in months) Holds own bottle * (give approximate age in months) Cup Drinking * (give approximate age in months) Finger Feeds * (give approximate age in months) Crawling * (give approximate age in months) Running * (give approximate age in months) First Words * (give approximate age in months) Dressing * (give approximate age in months) Utensil Use * (give approximate age in months) Straw Use * (give approximate age in months) Hand Dominance * Behavioral Concerns: Speech-Language Development A quiet baby? * Yes No A frequent crier? * Yes No Irritable * Yes No Visually alert and attentive? Yes No Auditorily alert and attentive? Yes No Did you child began to babble and stop? Yes No At present, does your child: Have understandable speech? * Yes No Have a loud voice? * Yes No Have a monotone voice? * Yes No Have a horse voice? * Yes No Have a stuttering problem? * Yes No Respond to sound? * Yes No Respond to loud sounds only? * Yes No Seem to willingly ignore sounds? * Yes No MEDICAL HISTORY List past/present medications: * List of significant illnesses and infections (give approximate dates): * List surgeries and hospitalizations (give approximate dates): List any allergies (food & nonfood): Did/does your child suffer from frequent ear infections? How many ear infections since birth? EDUCATIONAL BACKGROUND School * Grade * School Address * Address 1 Address 2 City State/Province Zip/Postal Code Country School Phone (###) ### #### Teacher * Academic Concerns Thank you for submitting!
