Has your child ever received a speech and language evaluation? if so, when? Has he/she attended therapy?

Transcription

1 Today s Date: Cleft Palate and Craniofacial Speech Disorders - Intake Form Welcome to Momentum Therapy Center. The information you provide on this form will help us prepare your child s upcoming speech-language evaluation. Please print and complete the form to the best of your ability. Mail or fax this form before the evaluation date. Child s Name: Gender: Age: Birthdate: Ethnicity/Race: American Indian/Alaska Indian, Asian, Black/African American, Hispanic/Latino, Native Hawaiian or Other Pacific Islander, White, Unknown Mother s Name: Home Phone: Cell: address: Father s Name: Home Phone: Cell: address: Home Address: Who is filling this questionnaire? Relationship to child: Medical or Developmental diagnosis: School Diagnosis: Who referred your child? Reason for referral: When did you first notice the issue(s)?: Has your child ever received a speech and language evaluation? if so, when? Has he/she attended therapy? Phone: (281) Fax: (281) of 6

2 Is he/she currently in therapy? Yes No If yes, where? Family Information Father s Occupation: Mother s Occupation: Marital Status: Single Married Separated Divorce Siblings: Name: Age: Name: Age: Name: Age: Name: Age: Who currently lives in the home? Primary language spoken at home: Are there any family members or relatives who have or had any speech, language, swallowing/feedings, issues or therapy? If yes, why? Pregnancy, Birth History, and Early Development Is this your biological child? Where there any complications during pregnancy? If yes, explain? Type of Delivery: Vaginal Caesarian Was the child born before 37 weeks gestation? Yes No Phone: (281) Fax: (281) of 6

3 Any complications during delivery? Yes No Child s Birth weight? Did the baby have trouble breathing? Yes No Was the baby on a respirator? Yes No If yes, how long? Speech: Describe how you child sounds when he/she talks? How do others describe how he/she talks? When your child talks about something unfamiliar to you, how much do you understand? How much do you understand when you know the context of what your child is talking about? How much do others understand when they are not familiar with what your child is talking about? How much do others understand when they are familiar with what your child is talking about? Phone: (281) Fax: (281) of 6

4 Feeding: Has your child ever experienced feeding difficulties? (e.g., as an infant, did milk or food come out of his/her nose when feeding? Yes No How old was your child? Birth 7 months 8 months 14 months Does your child experience feeding difficulties now? Yes No If yes, list types of foods/drinks? How often does it happen? with every meal once a day 3-5 times a week How long has the problem been present? Has your child had an adenoidectomy? Yes No Has your child ever had a swallow study? Yes No If yes, date of last exam? Where? Results: Surgeries: Has your child had any of the following surgeries? Yes No If yes, what type: (check all that apply) Palate repair Palate fistula repair How many? hospital: date: Pharyngeal flap or sphincter-pharyngoplasty Maxilla advancement/lefort procedure Other: hospital: date: hospital: date: hospital: date: hospital: date: Phone: (281) Fax: (281) of 6

5 How did your child s voice sound after surgery? Better Like he/she was talking though his/her nose like he/she had a cold Medical/Genetic Diagnoses: Has your child received a medical/genetic diagnosis? (check all that apply) Cleft lip Cleft palate Submucous cleft palate Hemifacial macrosomia Cancer with radiation to pharyngeal area Crouzon syndrome Apert syndrome Pierre Robin sequence with cleft palate Velocardiofacial syndrome Microtia (ear anomalies) Other: Hearing: Does your child have pressure-equalizing tubes? Yes No If yes, when was the surgery? Tubes were placed in which ear(s)? Left Right Both When was your child s most recent hearing evaluation? Results? normal slightly impaired moderately impaired deaf Phone: (281) Fax: (281) of 6

6 If your child has a hearing impairment, indicate which devices he/she uses: Hearing aids Cochlear implant Bone-anchored aids (BAHA) FM audio system (at home and/or home) Intervention: Has your child had speech/language therapy? Yes No If yes, where and when? Please describe the speech/language goals: Has your child been enrolled in an early intervention program? Yes No If yes, please describe the program? Primary reason for seeking therapy? What is your vision or goal for your child s individual education and emotional needs: Phone: (281) Fax: (281) of 6