Adult Intake FormPediatric Intake Form Date MM DD YYYY Child's name * First Name Last Name Date of birth MM DD YYYY Age Gender Diagnosis Date diagnosed MM DD YYYY Referred by GENERAL INFORMATION Mother/Caregiver Name Address Occupation Cell Phone (###) ### #### Home Phone (###) ### #### Work Phone (###) ### #### Email Emergency contact Phone (###) ### #### Nanny's name Phone (###) ### #### Father/Caregiver Name Address Occupation Cell phone (###) ### #### Home phone (###) ### #### Work phone (###) ### #### Email Emergency contact Phone (###) ### #### Nanny's name Phone (###) ### #### Brothers and sisters and other persons living in the home Name(s) Age(s) Speech & language issues Languages spoken in the home other than English? Yes No Does the child speak the language? Yes No Does the child understand the language? Yes No Which language does the child prefer to speak at home? SCHOOL HISTORY If your child is in school, please answer the following Name of school Grade Teacher's name What are your child's strengths? Is your child having difficulty at school? SPEECH - LANGUAGE - HEARING INFORMATION Do you feel your child has a speech or hearing issue? Yes No Please describe and state when you first became concerned Has your child had a speech evaluation? Yes No Has your child had a hearing evaluation? Yes No If yes, when and where? What were the results? Has your child ever had speech therapy? Yes No If yes, when and where? What was he/she working on? Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)? Yes No If yes, please describe Name Profession Date/Duration Email Phone (###) ### #### Is there a history of language and/or learning problems in the family? Yes No If so, please describe Has your child been examined an an Ear, Nose and Throat (ENT) doctor? Yes No If so, please list name, date(s) seen, address and phone number of doctor HEALTH AND DEVELOPMENTAL HISTORY Pregnancy and Birth Was there anything unusual about the pregnancy or birth Yes No If yes, please describe Was the mother sick during pregnancy? Yes No Please describe How many months was the pregnancy? Child's birth weight Did the child go home with his/her mother from the hospital? Yes No If the child stayed at the hospital, please describe why and for how long MEDICAL HISTORY Who is your child's doctor? Please list any medications your child takes regularly Does your child have a history of any of the following (please mark 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 issues Asthma Hearing loss Enlarged tonsils/adenoids (circle) Tonsillectomy Adenoidectomy Surgery Jaundice Upper respiratory infection High fevers Frequent throat clearing Frequent sore throats Laryngitis Loses 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 issues Choking Colic Obstructive sleep apnea Sleep disordered breathing Sleep study results Poor posture Forward head posture Difficulty to breastfeed Failure to thrive Visual issues Please explain if any of the above has been marked (including dates for ear tubes, tonsillectomy, adenoidectomy and quantity of ear infections) DEVELOPMENTAL MILESTONES Please list the approximate age your child achieved the following developmental milestones Babbled Said first words Combined two words Combined three words Used complete sentence Sat unsupported Crawled Walked Toilet trained Fed self with spoon Does your child Repeat sounds, words or phrases over and over? Understand what you are saying? Retrieve/point to common objects upon request (ball, cup, shoe)? Follow simple instructions ("Shut the door" or "go get your shoes")? Respond correctly to yes/no questions? Respond correctly to who/what/where/when/why questions? Ask questions to gain information? Stay on topic during conversation? Your child currently communicates using Body language Sounds (vowels, grunting) Words 2-4 word sentences Sentences longer than four words Other If other, please explain Behavioral characteristics Cooperative Attentive Willing to try new activities Plays along for a reasonable length of time Separation difficulties Easily frustrated/impulsive Stubborn Restless Poor eye contact Easily distracted/short attention Destructive/aggressive Withdrawn Inappropriate behavior Self-abusive behavior INTELLIGIBILITY Approximately how much of your child's speech do you understand? Less than 25% 25% 50% 75% 100% Approximately how much of your child's speech is understood by others? Less than 25% 25% 50% 75% 100% Please give an example of a typical daily diet for your child Breakfast Snack Lunch Snack Dinner Is your child a Slow eater Picky eater Messy eater Takes big bites DENTAL/ORTHODONTICS Has your child been seen by an orthodontist? Yes No If yes, what procedures were performed and what were the findings? Has your dentist or orthodontist diagnosed your child with a malocclusion? Yes No If yes, please deescribe Does your child have a history of any of the following? (please mark all that apply) Upper braces Lower bracesPalatal 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 has been marked Please list name, date(s) seen, address and phone number of dentist/orthodontist SLEEP Please check all that apply for your child 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 Bedwetting Does your child wake up multiple times/go to the bathroom Yes No If yes, how often? How many hours of sleep does your child get per night? Sleep position (mark all that apply) Back Stomach Left side Right side Has your child ever had a sleep study done? Yes No If yes, when and where? VOICE AND FLUENCY Do you have any concerns about your child's 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 child's fluency? Yes No If yes, please describe Are there any known voice problems among family members (past or present)? How would you classify the home environment (check as appropriate)? Quiet Moderately noisy Noisy Does voice change over the course of a day (check as appropriate)? Better in the morning Better midday Better at night Has the child had treatment for the problem before (check all that apply)? Diagnosis Surgery Voice therapy Pleas list date(s), name of surgeon/therapy and what was done Hydration Number of 8-oz glasses of water daily Mouth-breathing (0 never, 5 always) Sweating (0 never, 5 severe daily) 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) How would you describe your child's communication or voice use in general? Emotional reactions (e.g. aggressive, frustrated, angry, passive, quiet, etc.) Voice use patterns (e.g. in games, sports, singing, etc.) Situations invoking strong, emotional, or other exceptional voice use Please rate the following activities for the child, using the scale below 0= never, 2=rarely, 3=sometimes, 4=often, 5=always Does your child imitate other voices or characters during play? Does your child talk loudly? Does your child frequently clear his/her throat? Does your child frequently cough? Does your child yell or cheer? Do other family members yell or cheer? Does your child participate in sports, in school or otherwise? Does your child perform vocally (acting, singing, cheerleading)? Does your child have a singing coach? Does your child have a hoarse/raspy voice? ABOUT YOUR CHILD Please share the following. What are your child's favorite... Physical activities Quiet activities Games Books Music/songs Characters Do you have any other information you would like to share about your child? 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
