Pediatric Speech and Language Questionnaire Pediatric Speech and Language Questionnaire Today's Date(Required) Month Day Year Client InformationClient Name(Required) First Client Name(Required) Last Date of Birth Month Day Year Background InformationWhat are your primary concerns for this speech/language evaluation? When did you first notice this concern? Has your child received a speech and/or language evaluation? Yes No If yes, where? Please provide a copy of the speech and/or language evaluationMax. file size: 32 MB.Please list previous speech treatmentsLocationDateLength of time attendedNumber of times a weekTime length of the session Add RemovePlease provide a copy of previous speech treatmentsMax. file size: 32 MB.How has this issue changed since you first noticed it? What has been done about it? (goals and strategies) What has helped this concern? What has not helped this concern? What do you think was the cause? How does this issue affect your child? What are your child's strengths? What does your child like to do in their spare time? Do you feel like your child is a happy child? Please state any additional information or comments you feel would be helpful to us in evaluating your child's speech and language behavior. Medical HistoryCheck the following that apply to your child Hospitalizations Serious illness or accident Seizures History of ear infections PE tubes Tonsils and/or adenoids removed Vision problems Hearing problems Trouble sleeping Respiratory issues (e.g. history of pneumonia, URI) Allergies Other, not listed For any of the above that you selected, please share the following informationDate(s)Name of care provider Add RemoveCurrent Client CarePlease provide the information about the following, if your child is not currently under the care of any please leave that section blank. Name of the current pediatrician that your child is under the care of First Last Name of current ENT that your child is under the care of First Last Name of current psychologist/psychiatrist that your child is under the care of First Last Name of neurologist your child is under the care of First Last Name of Social Worker your child is under the care of First Last Name of Behavior Therapist your child is under the care of First Last Family Information/HistoryLanguage(s) spoken in the home Guardian's Occupation Guardian's Occupation SiblingsNameAge Add RemovePerson(s) living in the same home as your childNameRelationship to your child Add RemoveList any family members/relatives who have every received any kind of Special Education services.NameRelationship to your childServices they received Add RemoveList any family members/relatives who have had any speech, language, hearing concerns or therapyNameRelationship to your childIssue/Therapy received Add RemoveChild Education HistorySchoolName of schoolGrade of your child Add RemoveDoes your child receive any Special Education Services? Yes No Please specify and describe any challenging behaviors that you feel are of concern, and specific strategies or techniques that have worked or not worked well in school or at home to manage these behaviors (if applicable) Speech and Language HistoryHow does your child primarily communicate?(Required) What is the best way that your child learns/studies?(Required) Was/is your child quiet as a baby?(Required) Yes No Does/did your child coo and babble?(Required) Yes No Does/did your child cry excessively?(Required) Yes No Does/did your child speak first, real words?(Required) Yes No What was your child's first words?(Required)Word(s)Approximate Date or Age Add RemoveDoes your child combine two words?(Required) Yes No What were your child's first word combinations(Required)Word combinationsApproximate Date or Age Add RemoveDoes your child speak in complete sentences?(Required) Yes No If yes, approximately how many words? Does your child get frustrated by their difficulties or inability to communicate? Yes No If talking, can you understand your child's speech?(Required) Yes No They aren't talking yet If talking, can family members understand your child's speech? Yes No If talking, can strangers understand your child's speech? Yes No Does your child stutter?(Required) Yes No If yes, please describe how your child speaks Does your child follow directions?(Required) Yes No Does your child follow multi-step directions?(Required) Yes No Does your child play with any toys now?(Required) Yes No If yes, what toys? Does your child struggle with making friends?(Required) Yes No Does your child have any feeding challenges?(Required) Yes No Does your child have a tongue-tie?(Required) Yes No Is there any additional information that we should know about your child?(Required) Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) Last Phone(Required)Email(Required)
