Speech Language History
Client first name
Client last name
Date of birth
Who referred you to Pediatric Connections?
Why were you referred?
Client lives with
Please list all persons living in the home with names and relationship to client - including ages of all children in home.
Parent #1 Occupation
Parent #2 Occupation
Child's primary language spoken at home
Is there a language other than English spoken at home?
Was client born premature?
Describe birth history, including complications:
If client is under 18
Has your child had any of the following:
Date of ear tubes
Tonsillitis: How Often?
Other serious injury/surgery/hospitalizations (age & reason)
Last hearing exam
Results of hearing exam
Is client currently under the care of:
Select all that apply
Select all that apply
Choke on foods or liquids
Currently put toys/objects in mouth
Brush teeth/Allow brushing
Drool or pool saliva
Please tell the approximate age client achieved the following milestones:
Said 1st word
Put 2 words together
Spoke in short sentences
Speech-Language Hearing Information
Does the client have a latex allergy?
Your child currently communicates using the primary format of:
Body Language (pointing, gesturing)
Words (shoe, doggy, up)
2-4 word sentences
Sentences longer than 4 words
Other (sign language)
What are your child's strengths? What does your child like to do in his/her spare time?
Has your child ever had speech therapy/screening?
Where and when?
(i.e. School district, infant/toddler, private practice)
Was he/she dismissed?
List frequency and length of last service
Is your child aware of or frustrated by any speech/language challenges?
Does your child
Repeat sounds, words, or phrases over & over
Understand what you are saying
Retrieve/Point to common objects upon request (ball, cup, shoe)
Follow simple directions (shut the door, get your shoes)
Respond correctly to yes/no questions
Respond correctly to who/what/where/why questions
Make eye contact with others when communicating
Imitate others (physically or verbally)
Interact in play with other children
Take turns in simple games and structured activities
Join in on-going activities
Demonstrate appropriate personal space/body proximity with others
Initiate communication with others
Return and initiate greetings
Identify emotions of others by responding appropriately
Interpret body language
Self-regulate when upset or excited
Accept unexpected changes
Willing to try new activities
Easily distracted/short attention span
Plays alone for reasonable length of time
Flight-risk (runs away)
If your child is in school, please answer the following
Name of School
Has your child repeated a grade?
It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities as it relates to speech and communication:
Please state any additional information or comments you feel would be helpful in learning about your child's speech/language behavior: