Child Intake Form (To be completed by the parent or guardian and returned to the clinic) Phone: Select.
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1 NORTHEASTERN UNIVERSITY Speech, Language, and Hearing Center 30 Leon Street 503 Behrakis Health Science Center Boston, MA Ph: (617) Fx: (617) TODAY S DATE: Child Intake Form (To be completed by the parent or guardian and returned to the clinic) Name of child to be evaluated: Street: Zip Code: Sex: Phone: Date of Birth: Age: Grade: Referred by: Who should be contacted to schedule an appointment: Other Languages Spoken: Language Dominance: Father s name: Zip code: Date of Birth: Level of Education Completed: Phone: Age: Occupation: Mother s name: Zip code: Date of Birth: Level of Education Completed: Phone: Age: Occupation: Names of Brothers and Sisters: Age: Grade: Learning/Speech Problems?
2 2 Is there anyone else living in the home? Has there been a history of divorce or separation in this family? Description of speech and / or hearing problem 1. Please describe your child s speech or hearing difficulty. 2. When and how did the problem begin? 3. Who was the first person to notice the problem? 4. Does the child feel he / she has a problem? 5. Describe any changes in the problem since it began. Developmental History Pregnancy and Birth: (questions refer to the child to be evaluated) 1. How would you describe the mother s health? Before pregnancy? During pregnancy? After pregnancy? 2. Did the mother experience any of the following during pregnancy? Approximately when during pregnancy?
3 German Measles High Fever Kidney Infection Anemia Bleeding Swelling legs and/or arms X-rays Accidents Drugs Other: 3 3. Was the child full term or premature? (check one) Full term Premature If premature: How many weeks? Birth Weight: 4. Labor: More than 10 hours Difficult Less than 2 hours 5. Hospital where child was delivered: 6. Attending physician: 7. Delivery: Normal Cesarean Breech Forceps Anesthesia Other (describe) 8. Was breathing difficult to initiate in this child? 9. Did the child present any of the following problems at birth? Bruises/abnormalities in the head region RH incompatibility Cerebral Palsy Cleft lip / palate Need for oxygen Feeding problems Blood transfusions Other (describe below:) 10. Did the child receive any special medication or treatment at birth? 11. Is there any history of miscarriage or still birth?
4 4 Developmental Milestones 1. Please check if the infant: Cried excessively Resisted being held Was responsive to affection 2. Please indicate the approximate age when the following first occurred: held head up sat up crawled walked first babbled fed self with spoon achieved bladder control achieved bowel control stopped wetting at night said first words first combined words 3. Which hand does the child prefer to use? right left 4. Do you feel that the child has any of the following traits? highly active eating problems sleeping problems toilet-training problems problems playing with other children discipline problem unusual fears nervous habits strange behaviors that trouble you awkwardness and lack of coordination dental problems bed wetting other Describe: Health Record 1. Describe the child s general health. 2. Is the child currently under medical treatment or medication?
5 5 3. Who is your family physician or pediatrician? Name: Phone: Zip Code: 4. List and describe any hospitalization, operations, or accidents. 5. Please indicate if the child has had any of the following: mumps convulsions fainting spells measles tuberculosis ear aches/infections chicken pox pneumonia allergies whooping cough frequent laryngitis meningitis scarlet fever tonsillitis freq. sore throat high fever frequent colds other 6. Does the child ever complain about hearing noises (ringing, buzzing, roaring, etc.) in his/her ears? 7. Has the child been exposed to loud sounds (gunfire, heavy machinery, etc.)? 8. Does anyone in the family have a history of any of the following: Problem: speech, language problems hearing problems brain damage mental retardation cerebral palsy emotional disturbance/mental illness chronic illness (Please Specify Type: ) Relationship: Educational History 1. Level Attended (check if yes ) Dates nursery school, day-care Kindergarten 1st grade 2. Has the child been promoted regularly? 3. Is the child in a special class? 4. Is the child receiving tutoring in any subject area?
6 6 6. What school does the child attend now? Name: Phone: Grade: Principal s Name: Zip Code: Teacher s Name: 6. What is the child s attitude toward school? 7. What is the child s favorite school subject or activity? What subject / activity does the child complain about the most? 8. Please check any of the following that you feel are true of this child. discipline problem receives preferential seating difficulty learning to read speech/hearing problem affects school work difficulty learning to write complains of being teased by classmates about short attention span his/her speech Speech and Language Development 1. At what age did the child first put words together meaningfully? 2. Who was the child s primary speech model? 3. Has the child been exposed to more than one language? 4. Did the child stop talking or making sounds at some time? If so, at what age? 5. Have you always had difficulty understanding what the child is saying? 6. Which member of your household understands the child s speech the best? 7. Who has the most difficulty understanding the child? 8. Please check any of the following characteristics that are true of the child s speech NOW
7 out of breath while talking drools while he talking overly tense while talking holds breath while talking tries to talk faster than he/she can think more difficulty than others thinking what to say hoarse voice abnormally high pitched voice sounds like he/she is talking through his/her nose uses gestures instead of words to communicate uses single words only always talks too softly always talks too loudly doesn t talk, just makes grunting noises seems to stare at people when they talk won t answer you if he/she can t see you talk to him/her often refuses to talk to people 7 9. Does this child? a. hear when you call? b. hear the telephone? c. understand what you say? d. follow simple commands or requests? 10. Does this child usually ask for things by (please check one) making sounds using appropriate words using phrases or sentences pointing or gesturing getting a brother or sister to get it for him/her 11. Have you ever felt that this child had difficulty hearing? a. How old was the child when you first questioned his/her ability to hear? b. Has he/she ever had a hearing test? When? Where?
8 12. Does this child wear a hearing aid? a. Approximately when was it purchased? b. What is the make and model number? c. Who is your hearing aid dealer? d. Does this aid seem to be operating properly at this time? Has anything been done to improve your child s speech? Did the speech appear to improve? 14. Have you had this child evaluated by any other clinic? Name of Clinic: Address of Clinic: Date of Evaluation: Findings: 15. Has this child received speech therapy previous to this time? Place Dates Therapist May we have your permission to request information about the evaluation and/or therapy mentioned above to assist us in our evaluation of your present difficulty? If so, please fill out one of the attached AUTHORIZATION FOR RELEASE OF INFORMATION forms. If the evaluation and therapy took place in more than one place, please fill out one form for each setting. 16. To whom would you wish our reports to be sent? Name of person filling out this form: Date this form was filled out: Relationship to the child: Who suggested that you request an evaluation at Northeastern?
9 Name: Position: 9 Are there any limitations on your schedule that would make it impossible for you to come for an evaluation on any specific day? If you have any other information which you feel would be helpful to us in preparing for your evaluation, please write it in the space provided below. Thank you for your time in filling out this form.
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