Pediatric History

Contact Information

sarnoldslp@gmail.com

Today's Date

Child's Name

Nickname

Date of Birth

Sex

Male Female

Address

City

State

Zip Code

Home Phone

Family Information

Parent 1 Name

Parent 1 Occupation

Parent 1 Cell Number

Parent 1 Work Number

Parent 2 Name

Parent 2 Occupation

Parent 2 Cell Number

Parent 2 Work Number

Siblings

Sibling 1 Name

Sibling 1 Age

Sibling 2 Name

Sibling 2 Age

Sibling 3 Name

Sibling 3 Age

Sibling 4 Name

Sibling 4 Age

Sibling 5 Name

Sibling 5 Age

Care Giver Information

Pediatrician

Address

Phone Number

Reason for Referral

Referred By

Has your child ever been treated or evaluated for speech or language services?

Yes No

If yes, please specify type and place of therapy

Does your child currently receive any type of therapy?

Yes No

If yes, please specify type and place of therapy

What language(s) are spoken in the home?

What language(s) does your child speak?

Birth History

Length of Pregnancy

Birth Weight

Did you have any difficulties during pregnancy

Yes No

If yes, please specify

Medical History

Has your child's vision been tested in the last year?

Yes No

If yes, by whom and the results

Has the child's hearing been tested in the last year?

Yes No

If yes, by whom and the results

Has your child been seen by a neurologist?

Yes No

If yes, by whom and the results

Has your child been seen by an ENT?

Yes No

If yes, by whom and the results

Have there been any hospitalizations at or since birth?

Yes No

If yes, date and reason for hospitalization

Is your child currently on any medication?

Yes No

If yes, medication name and reason

Other types of equipment please list and explain

Developmental Milestones

First Smile

Rolled Over

Crawled

Sat Unassisted

Stood Unassisted

Stood Assisted

Walked

Held own bottle

First Babble

Short text field

First Word

Combined 2 or More Words

Formed Sentences

How does your child make his/her needs known?

Does your child use language meaningfully?

Yes No

Does your child engage in conversational interactions?

Yes No

Do the following people understand your child's speech?

Mother

Father

Siblings

Grandparents

Teachers

Other Friends

Is your child toilet trained at this time?

Yes No

Please describe your child's eating habits

Does your child drink from a bottle or cup?

What food consistencies does your child eat (solids, purees, etc)?

Does your child feed himself/herself

Yes No

What are your child's favorite foods

What foods does your child dislike?

Educational History

What school does your child attend?

What grade is your child in?

Does your child like school?

Is your child receiving any services at school? If so, please describe.

Please check the areas of concern for your child

Reading

Writing

Math

Socialization

Do you feel your child can organize his/her work adequately

Yes No

Is there any other information that you think would be helpful to us as we evaluate and/or treat your child?

Do you have any other concerns?

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