Speech Intake Form | Lori Kilpatrick Pedi

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PATIENT INTAKE FORM

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Speech Patient Intake Form

SPEECH NEW PATIENT INTAKE FORM

Please complete the new patient Speech history information intake form below.

CHILD INFORMATION

Child Full Name

Child Date of Birth

Parent/Legal Guardian Name

Phone

Email

SPEECH / LANGUAGE / HEARING HISTORY

Do you feel your child has a speech problem?

Do you feel your child has a hearing problem?

Has he/she ever had a speech evaluation screening?

Has he/she ever had a hearing evaluation screening?

Has he/she ever had speech therapy?

Speech problem? If yes, please describe

Hearing problem? If yes, please describe

Speech Evaluation? If yes, please list location of screening, approximate date of screening and what you were told.

Hearing Evaluation? If yes, please list location of screening, approximate date of screening and what you were told.

Speech Therapy? If yes, please describe.

Has he/she ever had any other therapy? (Physical, Occupational, counseling, vision, etc.?)

Other Therapy? If yes, please describe.

Is your child aware or frustrated by any speech/language difficulties? Please describe.

What do you see as your child's most difficult problem in the home?

What do you see as your child's most difficult problem in the school?

DEVELOPMENT HISTORY

Please tell the approximate age your child achieved the following development milestones.

sat alone

babbled

spoke in short sentences

grasped crayon/pencil

walked

said first words

toilet trained

put words together

Does your child...

Choke on food or liquids

Currently put toys/objects in mouth

brush his/her teeth or allow brushing

CURRENT SPEECH / LANGUAGE / HEARING

Does your child...

repeat sounds, word or phrases over and over?

understand what you're saying?

retrieve/point to common objects upon requests (ball, cup, shoe)?

follow simple directions (shut the door, get your shoes)?

respond correctly to yes/no questions?

respond correctly to who/what/when/where/why questions?

Does your child communicate using...

body language

sounds (vowels, grunting)

words (shoe, dog, up)

2 to 4 word sentences

sentences longer than 4 words

Behavioral Characteristics

cooperative

attentative

willing to try new activities

plays alone for lengths of time

seperation difficulties

easily frustrated/impulsive

stubborn

restless

easily distracted

poor eye contact

destructive/aggressive

withdrawn

innappropriate behavior

self-abusive behavior

Additional Comments

SIGNATURE

By checking this box and signing below, I agree to the terms listed within this form. I confirm that I am the authorized parent/legal guardian for the child as detailed within this form.

Your Signature

Thanks for submitting our patient intake form. You may click the link below to return to the home page.

Please click the button to complete the intake form for the services you are seeking for your child.

13219 Hugh Seymour Ln . Ocean Springs, MS 39564

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