ATLANTA SPEECH SCHOOL 3160 NORTHSIDE PARKWAY, NW ATLANTA, GA APPLICATION AND CASE HISTORY QUESTIONNAIRE SUMMER PROGRAMS
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1 ATLANTA SPEECH SCHOOL 3160 RTHSIDE PARKWAY, NW ATLANTA, GA APPLICATION AND CASE HISTORY QUESTIONNAIRE SUMMER PROGRAMS DATE: CHILD S NAME: BIRTH DATE: S. S. # PARENTS: ADDRESS: TELEPHONE: (Full Name & Nickname) City State Zip Code SCHOOL: GRADE: TEACHER'S NAME: If child is in private school, also indicate public school/system in your area. SCHOOL SYSTEM: PUBLIC ELEMENTARY SCHOOL: FAMILY PHYSICIAN, PEDIATRICIAN, OR OTHER PERTINENT PROFESSIONALS: (Include specialty): REFERRAL: Who referred you to the Speech School? State your primary concern: When was this difficulty first noticed? How did your child's school describe the difficulty? What factors do you think might have contributed to the difficulty? Does your child feel he/she has a problem? (If so, describe these feelings.) Previous Testing: (Note dates and findings - Please send reports.)
2 FAMILY BACKGROUND Father's Name: Mother s Name: (Legal Name) (Legal Name) Age: Education: Age: Education: Occupation: Occupation: Employer: Employer: Business Phone: Business Phone: Marital Status: Married: Separated: Divorced: Remarried: Widow: Other children in the family: Name: Age School Grade Name: Age School Grade Name: Age School Grade Name: Age School Grade (Indicate if there have been any speech, hearing, learning or physical problems with brothers and sisters.) Is there any history of learning, hearing, psychological or hereditary problems in the family? If so, please describe. BIRTH AND PRENATAL HISTORY Length of pregnancy with this child: If anesthetics were used, what kind? Duration of labor Weight at birth For each of the following, circle YES or and give explanations when necessary. RH Incompatibility... YES Other complications during pregnancy.. YES Medications during pregnancy... YES Breech Birth... YES Caesarean Delivery... YES Forceps used... YES Oxygen was needed... YES Child was jaundiced... YES Transfusions given... YES Baby was in incubator... YES
3 Postnatal Conditions: Scars, bruises, deformities at birth... YES Sucking and swallowing problems... YES Feeding difficulties in early infancy... YES DEVELOPMENT (List approximate ages) Sat unsupported: Crawled: Walked: Trained for bladder: Trained for bowels: MEDICAL HISTORY For each of the following, circle YES or and give age at which illness occurred. Meningitis YES Encephalitis... YES Convulsions or seizures... YES Allergies... YES Ear infections: (comment on frequency and duration): List any other childhood diseases, child's age and severity. Indicate whether there were any changes in behavior following the illness. Note any high fevers and their duration: Has your child had surgery? What type? Has your child ever been seen by a neurologist? Who? Findings: When? When? What medications have been used with your child? (For each medication, list when and for what reason.) Is your child currently on any medication? If yes, what? For what?
4 VISUAL Have you or others been concerned about your child's visual behaviors? (Blinking, crossing of eyes, watering, etc.) Has your child been seen by an eye specialist? If so, give name, date and findings? Glasses? AUDITORY Has your child ever had a hearing problem? If so, please describe the nature of the problem and by whom it was treated: When was the last time your child had his/her hearing tested (audiometric testing)? Does your child have any difficulty following directions at home or in group situations? Does your child have trouble remembering? (address, phone number, events, etc.) Describe how he/she responds to various types of sound such as speech, loud noises, telephone ringing, whispered speech: LANGUAGE Speech and Language History Age at which your child said: First words? Made word combinations? ("Want cookie" or "Me out") Used complete sentences? Example: Has your child ever had difficulty understanding what was said? Present Language Can your child's speech be clearly understood? Comments: Named familiar objects? Does your child appear to know the word he/she wants to say but seems unable to get the word out? Has your child been seen for a speech/language evaluation? If yes, by whom? Results: Has your child ever received speech therapy? Reason for therapy? Length of time seen? Age when seen? Success of therapy?
5 MOTOR Does your child seem awkward or uncoordinated? What sports does he/she enjoy? Prefer right or left hand? Does he/she have problems: Coloring/painting: Puzzles: Cutting: Writing: Pasting: Others: SOCIAL BEHAVIOR What are your child's interests and hobbies? Describe your child's attention span? How well does your child organize the way he/she does things? (homework, house chores, etc.) Does he/she seem to "tune in and out" of listening situations? For each of the following, circle YES or and give explanations if necessary: Eats well... YES Sleeps well... YES Nervous... YES Wets Bed... YES Has temper tantrums... YES Plays well with brothers & sisters... YES Easily distracted... YES Independent... YES Plays well with other children... YES Prefers playing alone... YES Sucks thumb... YES Tells lies... YES Extremely active... YES Easily managed in home... YES Withdrawn... YES Frustrates easily... YES How is your child disciplined? How well does your child anticipate the consequences of his/her behavior? Comments:
6 EDUCATIONAL HISTORY Please list all school attended by your child: School Grades Any Problems? Has your child repeated any grades? Subjects child does well in: Has your child received tutoring or resource assistance? Is he/she currently receiving remedial help? If so, from whom? Has your child received an OT/PT evaluation? Date: Is your child receiving or has received Occupational Therapy? Has your child been tested by Joint Admissions Testing Program? When? (If yes, please send copy of results.) Do you plan to have your child tested by Joint Testing during the next year? When? Has your child been seen at the Atlanta Speech School before? If yes, when? For what? Have you contacted us before? If yes, why? Person(s) completing the Parent Questionnaire:
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