Pediatric Intake FormAdult Intake Form Name Date MM DD YYYY Date of birth MM DD YYYY Age Gender Referred by Diagnosis Date diagnosed MM DD YYYY Primary concern Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation Cell phone (###) ### #### Home phone (###) ### #### Work phone (###) ### #### Email Emergency contact SPEECH - LANGUAGE - HEARING INFORMATION Do you have a speech or hearing issue? Yes No Please describe and state when you first became concerned Have you ever had a speech evaluation? Yes No Have you ever had a hearing evaluation? Yes No If yes, when and where? What were the results? Have you ever had speech therapy? Yes No If yes, what was the therapist working on? Approximately how well is your speech understood by others? Less than 25% 25% 50% 75% 100% Languages spoken in the home other than English? Yes No If yes, please list Have you ever had any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)? Yes No If yes, please describe Name Profession Date/duration Phone/email Is there a history of voice/speech/language/sleep/swallowing issues in the family? Yes No If yes, please describe MEDICAL HISTORY Who is your primary care physician? Please list any medications you take regularly Do you have a history of any of the following? (check all that apply) Lips open at rest Mouth breathing Ear infections Ear tubes Hospitalization Intubation/ventilator Seizures Jaw clicking or popping Reduced jaw opening Facial trauma Facial pain Headaches Head injury Allergies Sensitivities Sinus problems Asthma Hearing loss Enlarged tonsils/adenoids (circle) Tonsilectomy Adenoidectomy Surgery Jaundice Upper respiratory infection High fevers Frequent throat clearing Frequent sore throats Laryngitis Loss of voice Bronchitis Breathing difficulty Pneumonia Gastroesophageal Reflux (GERD) Stomach aches Tongue-tie/short lingual frenum Labial frenum (upper lip) Family history of tongue-tie Aspiration Swallowing problems Choking Colic Obstructive sleep apnea Sleep disordered breathing Poor posture Forward head posture Difficulty to breastfeed Failure to thrive Visual problems Please explain if any of the above has been marked (including dates for ear tubes, tonsillectomy, adenoidectomy and quantity of ear infections) Please give an example of a typical daily diet Breakfast Snack Lunch Snack Dinner DENTAL/ORTHODONTICS Have you ever been seen by an orthodontist? Yes No If yes, what procedures were performed and what were the findings? Has your dentist or orthodontist diagnosed you with a malocclusion? Yes No If yes, please describe Do you have a history of any of the following? (please mark all that apply) Upper braces Lower braces Palatal expansion Headgear Extraction of permanent teeth Number of teeth lost Functional appliance Retainer Night guard Other oral appliance Please explain if any of the above have been marked Please list name, date(s) seen, address and phone number of dentist/orthodontist Please check all that apply during the night Snoring Grinding/clenching of teeth Feeling tired throughout the day Gasping for air Wake up feeling tired Move/toss around a lot Lips apart/mouth open Sleep walk Do you wake up multiple times/go to the bathroom? Yes No If yes, how often? How many hours of sleep do you get per night? Sleep position (mark all that apply) Back Stomach Left side Right side Have you ever had a sleep study done? Yes No If yes, when and where? VOICE AND FLUENCY Have you been examined by an Ear, Nose and Throat (ENT) doctorr? Yes No If yes, please list name, date(s) seen, address and phone number of doctor Do you have any concerns about your voice? Yes No If yes, please describe If yes, when was the problem first noticed (approximate date and circumstances, e.g. illness, change in daily routine, etc.)? Do you have any concerns about your fluency? Yes No If yes, please describe Are there any known voice issues among family members (past or present)? How would you classify the home/work environment (check as appropriate)? Quiet Moderately noisy Noisy Does your voice change over the course of a day (check as appropriate)? Better in the morning Better midday Better at night Have you had treatment for the issue before (check all that apply)? Diagnosis Surgery Voice therapy Please list date(s), therapist/surgeon name and what was done Hydration Number of 8-oz glasses of water daily Mouth breathing (0=never, 5=always) Sweating (0=never, 5=always) Inflammation risk Spicy, acidic food or beverages (0=never, 5=severe daily) Exposure to smoke (0=never, 5=severe daily) Voice information Aggressive throat clearing unrelated to eating or drinking (0=never, 5=always) Aggressive throat clearing related to eating or drinking (0=never, 5=always) Aggressive coughing unrelated to eating or drinking (0=never, 5=always) Aggressive coughing related to eating or drinking (0=never, 5=always) Voice use Are you a professional voice user? Yes No If singer, what voice type? Soprano Alto Tenor Baritone Bass How much do you use your voice throughout the day? How many hours? What % on a typical day? Variation of issue No difference in voice Worsens after extended use Worsens after moderate use Worsens after brief use Worsens with stress Worsens after singing briefly Trouble with Projecting voice High range Midrange Low range Entire range Speaking/singing softly Speaking over noise Rate of speech Previous voice care or training? Yes No If yes, please describe Other approaches to improve voice Please rate the following activities using the scale below 0= never 2=rarely 3=sometimes 4=often 5=always Do you talk loudly? Do you frequently clear your throat? Do you cough frequently? Do you yell or cheer (e.g. sporting events)? Do other family members yell or cheer? Do you have any other information you would like to share with us? Thank you for completing this form. Christine will review your responses and get back to you shortly. Please sign the following forms Policy Agreement Attendance and Cancellation Policy Notice of Privacy Practices
