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Test
Child's Name
Child's Date of Birth
Child's Age
Parents/Caregivers Names
Parent's Email
Street Address
City
State
Zip
Home Phone Number
Cell Phone Number
Child's School Name
Grade
Pediatrician
Pediatrician's Phone
Insurance Carrier
Reason For Referral (please describe your child's problem as fully as possible)
Mother's Health During Pregnancy
Pregnancy Duration
Birth Weight
Multiple Births
Yes
No
Complications (please check all that apply)
Rapid
Prolongued
Breech
Caesarean
Other
Baby's Health (please check all that apply)
Jaundice
Breathing Problems
Incubator
Abnormalities
Medical Conditions
Please Elaborate
Feeding problems as an infant?
Yes
No
Describe crying the first year (type, amount)
At what age did your child roll front to back?
At what age did your child sit without support?
At what age did your child roll front to back?
At what age did your child crawl?
At what age did your child stand?
At what age did your child walk?
At what age did your child complete toilet training?
At what age did your child complete toilet training?
Does your child have any speech problems or delays?
Yes
No
At what age did your child babble?
At what age where his/her first words:
At what age combine his/her first two words?
Do you understand your child's speech?
If so, how often (seldom, 50%, most of the time):
Do strangers understand your child’s speech?
How many words does he/she string together:
Describe your child’s speech:
Does your child understand and/or speak another language besides English?
Yes
No
Please specify:
Do you think your child has a hearing problem?
Has your child’s hearing been tested?
Yes
No
By whom?
Findings:
Has your child had any of the following conditions:
RSV
Measles
Rubella
Chicken Pox
Mumps
Lyme’s
GERD
Asthma
Torticollis
High Fever (specify what age)
Ear infections (specify how many and at what age)
Hypotonia
Sprains/fractures (specify where)
Other
Other/Comments
Has your child been diagnosed with any of the following neurological conditions:
Autism Spectrum
ADHD
Seizures
Head Injury
Other
If you selected "other", please explain:
Has your child seen any specialists (please specify):
Any hospitalizations/surgeries/illnesses?
Any other traumas, injuries?
Is your child on any medications:
Does your child have any allergies:
Have your child’s eyes been examined?
Yes
No
By whom?
Findings?
How well does your child eat?
Picky eater?
Any diet restrictions:
Any current difficulties with chewing, swallowing, feeding?
How well does your child fall asleep?
Does your child sleep through the night?
Ages of child's siblings:
Describe your child’s personality:
What are his/her favorite activities/interests:
Describe how your child acts in a social situation with peers.
Does your child have difficulty in any of the following areas:
Learning Problems
Handwriting
Reading
Riding a Bike
Gym/Sports
Do you have any other comments that you feel might be helpful to us (family issues, family history of delays, behavior problems)?
Are you currently receiving services elsewhere (Behavior Support, Speech, Occupational Therapy, Physical Therapy)?
Yes
No
Are you currently receiving support services at school (please specify):
Have you received any of the above services in the past?
Yes
Option 3
No
How did you hear of this facility?
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Speech
Toddlers
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