Pediatric Speech and Language Questionnaire

Pediatric Speech and Language Questionnaire

Today's Date(Required)

Client Information

Client Name(Required)
Client Name(Required)
Date of Birth

Background Information

Has your child received a speech and/or language evaluation?
Max. file size: 32 MB.
Please list previous speech treatments
Location
Date
Length of time attended
Number of times a week
Time length of the session
 
Max. file size: 32 MB.

Medical History

Check the following that apply to your child
For any of the above that you selected, please share the following information
Date(s)
Name of care provider
 

Current Client Care

Please 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
Name of current ENT that your child is under the care of
Name of current psychologist/psychiatrist that your child is under the care of
Name of neurologist your child is under the care of
Name of Social Worker your child is under the care of
Name of Behavior Therapist your child is under the care of

Family Information/History

Siblings
Name
Age
 
Person(s) living in the same home as your child
Name
Relationship to your child
 
List any family members/relatives who have every received any kind of Special Education services.
Name
Relationship to your child
Services they received
 
List any family members/relatives who have had any speech, language, hearing concerns or therapy
Name
Relationship to your child
Issue/Therapy received
 

Child Education History

School
Name of school
Grade of your child
 
Does your child receive any Special Education Services?

Speech and Language History

Was/is your child quiet as a baby?(Required)
Does/did your child coo and babble?(Required)
Does/did your child cry excessively?(Required)
Does/did your child speak first, real words?(Required)
What was your child's first words?(Required)
Word(s)
Approximate Date or Age
 
Does your child combine two words?(Required)
What were your child's first word combinations(Required)
Word combinations
Approximate Date or Age
 
Does your child speak in complete sentences?(Required)
Does your child get frustrated by their difficulties or inability to communicate?
If talking, can you understand your child's speech?(Required)
If talking, can family members understand your child's speech?
If talking, can strangers understand your child's speech?
Does your child stutter?(Required)
Does your child follow directions?(Required)
Does your child follow multi-step directions?(Required)
Does your child play with any toys now?(Required)
Does your child struggle with making friends?(Required)
Does your child have any feeding challenges?(Required)
Does your child have a tongue-tie?(Required)

Responsible Party Information (Client or Parent/Guardian)

Name(Required)
Name(Required)