Medical History Intake Form - Child Language & Developmental SpeechChild Language & Developmental Speech

Family Information

Name of Child

First Last

Age

Birth Date

Person Completing Form

First Last

Relationship

Name of family members living at home:

Language(s) spoken in the home:

Medical History

Were there any problems during pregnancy or difficulties at birth?

Yes
No

Was your child born before the due date?

Yes
No

Has your child been hospitalized at any time?

Yes
No

Has your child had his or her vision checked?

Yes
No

Are there any diagnosed mental, physical, or emotional disabilities?

Yes
No

Does your child have any allergies?

Yes
No

If you checked "YES" to any of the above, please explain or describe here:

Hearing Status

Does your child talk in a very loud voice?

Yes
No

Does your child turn up the volume on the radio and TV?

Yes
No

Does your child hear you if his or her back is turned?

Yes
No

Does your child hear you if you talk to him or her from the other room?

Yes
No

Does your child have a history of year infections?

Yes
No

How many? When was the most recent?

Has your child had a hearing test?

Yes
No

Additional Comments or Examples:

Communicating With You

How does your child usually let you know what he or she wants? Check all that apply:

Cries
Points to what he or she wants
Uses a few words
Makes a few different sounds
Makes many different sounds
Uses gestures (e.g., gestures for "give it to me")
Says many words, but no phrases or sentences
Says two or three-word sentences
Uses long sentences

Additional comments/examples:

Does your child answer when you talk to him or her?

Yes
No

Does your child talk about what he or she is doing?

Yes
No

Does your child ask for help?

Yes
No

Can the family understand your child's speech?

Yes
No

Can people outside of the family understand your child's speech?

Yes
No

What does your child talk about?

Previous Therapy/Treatment

My child ______ been enrolled in therapy/treatment before.

has
has not

Comments about previous therapy:

I think my child has trouble with:

I would like my child to learn how to: (Rank by most important to least important)

My family ______ available to participate in the treatment program.

is
is not

Additional Concerns

Child Language & Developmental Speech (CLADS)

Helping Children Reach Their Full Potential.

Medical Intake - Speech Therapy

Family Information

Medical History

Hearing Status

Communicating With You

Previous Therapy/Treatment

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