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1 Amy Reinstein, M.S., CCC SLP Speech Language Pathologist Amy Reinstein Speech & Language Therapy, Inc., 442 East 75 th Street, New York, NY Phone: Fax: CLIENT HISTORY CHILD (Please complete the form to the best of your ability and return it prior to your evaluation appointment. I will review this form with you and help you complete it during our visit with your child.) (Please include copies of related evaluations and/or current IEP s) Today s Date Child s Name Sex Age Birthdate Mother s Name Home phone Cell Father s Name Home phone Cell Home Address Who is filling out this questionaire? Relationship to child What are your concerns regarding your child s speech and/or language? When did you first notice the issue(s)? Do you feel that your child s speech and/or language is different than children his or her own age? If so, how?
2 Who have you seen regarding these issues? (Ie, Doctor s, Psychologist, etc., Include name, address and telephone number) Has your child ever received a speech language evaluation? How has this issue changed since you first noticed it? When? What has been done about it? What has helped/not helped the issue? What do you think was the cause? How does the issue effect your child? Family Information Language(s) spoken in the home Father s occupation Level of Education: Father Mother s occupation Mother Siblings: Names & Ages Are there any family members or relatives who have or had received any kind of Special Education Services? Are there any family members or relatives who have or had any speech, language, or hearing issues or therapy?
3 Pregnancy, Birth History and Early Development Is this your biological child? During pregnancy with this child, did mother have any illnesses? If so, what? Take Medications? If so, explain: Was labor at all problematic? If so, explain: Was the child s birth at all problematic? If so, explain: Type of Delivery: Vaginal Caesarian If yes, reason: Did your child have any trouble breathing after birth? an incubator? If so, explain Was the child kept in Was feeding a problem? If so explain Bottle fed? Breast fed? Age weaned from breast? Weaned from bottle? Age drank independently from an open cup finger fed self Is your child able to eat with a spoon and fork? problems eating now? Does your child have any Is he/she a picky eater? If yes, please explain Does your child eat: Pureed foods? Crunchy foods? Yogurt/Pudding Cookies/Pretzels Was your child very active as a baby? When did your child first learn to: Crawl? Sit alone? Feed self? Dress self? Walk independently? How well does your child: Walk? Run? Throw a ball? If your child has difficulties with any of the above or any other motor activies, please explain: Is your child toilet trained? If so, what age? Does your child wet the bed now? How often?
4 What hand does your child use to: eat? Draw? Write? Throw? How would you describe your child s current physical development? Medical History Pediatrician s name, address, and telephone number: Has your child ever been hospitalized? Age and reason: Has your child ever had any serious illnesses or accidents? Explain Has your child ever fainted? Had seizures? Does your child have problems hearing? Ear Infections? If so, how many? Last hearing exam date and results: Has your child had middle ear tubes inserted? If so, when? Did your child have his/her tonsils/adenoids removed? If so, when?: Does your child have any problems seeing? Does your child have any trouble sleeping at night? Wear glasses? Waking up in the morning? Does your child have allergies or asthma? What medications if any is your child on? Is your child presently being treated by a pediatrician? Psychologist? Therapist? Neurologist? Physical Therapist? Occupational Therapist? ENT? Any other pertinant medical history?
5 Speech History Was your child very quiet as a baby? Did he/she coo? Babble? Did your child cry excessively as a baby? When did your child speak single words (other than mama or dada ): What were your childs first few words? Approximately how many words did your child have at around 18 months? When did your child begin to combine words (two words)? Does your child use speech consistently to communicate? Frequently? Occasionally? Never? Does your child use gestures to communicate? How does your child primarily communicate? Explain Does your child get frustrated by his/her difficulty or inability to communicate? Does your child speak in complete sentences? If your chid talks now, can you understand? Can family members? Can strangers? Do you think your child stutters or stammers? If not, describe how he/she speaks Does your child answer questions? Does your child follow directions? Reading and Writing (if age appropriate please complete) Has your child had any problems learning to read? Learing to write? Do you/did you read to your child? Does/did your child enjoy being read to? What does your child enjoy reading? Dislike reading?
6 Does your child know the alphabet? learning/using new words? Does your child have difficulty Does your child have difficulty learning/retaining new information Can your child write well for his/her age? Math Has your child had difficulty learning math? Does your child like/dislike math? If so, explain: Cognitive Development Which toys did your child play with as at age months? At age months? Does your child play with any toys now? If so, what? Does your child seem to learn quickly? Slowly? Is he/she an average learner? How would you describe your child as the best way he/she learns/studies? Does your child have difficulty solving everyday problems? Provide an example if possible: Reasoning? If so, explain: Does your child have difficulty following muti-step directions? Educational History Where does your child attend school? What grade does your child attend? Has your child had any problems in school? Making friends?
7 Has your child s teachers had any complaints about your child s behavior, learning, or social development? If so, explain: Has your child worked with tutors Has this helped? With resource teachers? Does your child receive any Special Education Services? Describe any behaviors that you feel are of concern: Please Specify: What are your child s strengths? What does your child like to do in his/her spare time? Do you feel your child is a happy child? Please state any additional information or comments you feel would helpful to me in evaluating your child s speech/language behavior:
8
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