QUESTIONNAIRE - CHILD FLUENCY

Transcription

1 QUESTIONNAIRE - CHILD FLUENCY CANCELLATION POLICY: IF YOU NEED TO CANCEL YOUR APPOINTMENT, PLEASE CALL AT LEAST ONE WEEK PRIOR. THIS DOES NOT APPLY IN THE CASE OF ILLNESS OR UNFORESEEN CIRCUMSTANCES OF COURSE: Please complete this information and mail it back to me as soon as possible. If you have any previous evaluations or reports that you feel would be helpful, please send them with this form. Your evaluation/initial session is scheduled for at. 1. IDENTIFYING INFORMATION: Client s Name: Street Address: Town: State: Zip Code: Telephone: Home Work: Cell: Birth Date: Age: Parent s Names: Any Languages Other than English Spoken in the Home: Family physician/pediatrician: Physician Address/Phone: Referred by: Name of person filling out questionnaire: Work/Occupation: Self: Mother: Father: Employer(mother): Employer (father) Insurance Carrier: ID# Name of Person with Primary Insurance:

2 2. FAMILY HISTORY: Child lives with: 1) Both parents 2) Mother 3) Father 4) Other* *If other, please explain: Names and ages of brothers and sisters (or other children in household): Is there any history of speech, language, and/or hearing problems in other family members? If so, please describe: 3. DEVELOPMENTAL HISTORY: Pregnancy and Birth: Please check one: Full term: Pre-term Delivered after 40 wk gestation If not delivered at term, please explain: Delivery was: Induced: Why? Vaginal: C-Section: Birth Weight: Apgars: Other Info: Please describe any unusual problems or complications during or after birth: Milestones: List the approximate age when your child first began to: Sit Alone: Crawl: Walk: Feed Self w/ Spoon: Dress Self: Was fully toilet trained: Coo: Babble: Use Jargon: Use Single Words: Combine 2 Words: Combine 3 or More Words: Show a hand preference: Right: Left: Does he/she fall or lose balance easily? Seem awkward? Describe any other relevant information:

3 Sensory: Please list any sensory issues you are aware of or suspect (e.g. sensitivity to or cravings for smell, taste, tactile, sound, movement, etc.): Feeding: Was your child breast or bottle fed? For how long? Was there a transition from breast to bottle and if so at what age? When were bottles given up completely? At what age did you introduce spoon feeding (i.e. soft cereals) Did your child have any difficulty with pureed (Stage 1 & 2) foods? If yes, please explain: At what age were solids introduced? Problems? Child s current weight? Any history of gastroesophageal reflux (GERD)? Till what age? Medications for reflux? What? Current? History of constipation? How is/was it treated? Has feeding been a problem? Is current diet varied or is child a picky eater? Are there aversions to particular textures (e.g. purees, crunchy, chewy), temperatures, or consistencies? Explain: Please describe any issues (e.g. - hoarding or pocketing food, mouth stuffing, aspiration, choking, gagging, long time chewing, messy eating, etc.) Oral Habits: Please check all that apply. List ages when present or noted: Thumb Sucking: Age: Pacifier Use: Age: Tooth Grinding: Age: Drooling: Age: Cheek Biting: Age: Tongue Biting: Age: Sippy Cups: Age: Mouth Breathing: Age:

4 Tooth Brushing: How does your child respond to this? 4. MEDICAL HISTORY: List below, all illnesses, accidents, and operations which the child has had, and indicate the severity. Illness Age of Child Duration Severity Aftereffects Any Hospitalizations? When? Why? Any history of seizures of convulsions? When? Please indicate any medical diagnosis that has been made (e.g. ADHD, PDD-Autistic Spectrum, chromosomal, syndromes, etc...) and the at at which diagnosis was made: Any other suspected conditions which are currently being investigated or have been ruled out: Any other significant health problems that might have affected speech and language development? Yes No If yes, please explain: Is your child in good health at this time? Yes No If no,please explain: Any suspected or diagnosed allergies (e.g. - food or environmental)? Yes No If yes, to what: History of ear infections? How Frequent? Were tubes ever inserted? When? Are tubes still in? Does your child appear to have any difficulties hearing? Was hearing ever tested? Where? Results: Please list the names, addresses, and phone numbers of all other physicians besides your primary who care for your child (if applicable):

5 5. EDUCATIONAL HISTORY: Name of School Attending: Address: Phone: Teacher: Your child s current grade: Special Placement? Yes No If yes, what type of class is your child enrolled in? Student/teacher/aide ratio: Does your child have a 1:1 aide/teacher s assistant? How much time spent 1:1 with your child in course of school day? Have any grades been repeated? Yes No If yes, which one? Typical academic performance: Has your child ever been evaluated in school, through Early Intervention (EI), or privately? Yes No If yes, what evaluations were conducted (e.g. psychological, educational, speech/language, occupational therapy, sensory integration, physical therapy, etc.) and who performed the assessments? (please list both evaluators names as well as agencies if relevant): Has your child s behavior ever been an issue in school? Yes No If yes, please explain: Has your child ever had any speech/language therapy? Yes No If yes, with whom? School-Based Therapy: Freq/Duration Therapist s Name (Speech, OT, PT, Counseling,etc.) (Specify X per wk/group/indiv)

6 Other School-Based Services Freq/Duration Teacher s Name (e.g. remedial reading/math, ABA, 1:1 aide, resource room etc). 6. PRIVATE THERAPY: Type Therapist s Name: Agency: Phone: Any pertinent information regarding private therapies you are receiving or have received in the past? 7. SOCIAL HISTORY: Does/did your child attend Nursery School and/or regular group activities with other children? Yes No If yes, where? How does your child relate to other children? What comments have other adults, (e.g., teachers, family, friends) made about your child s speech and language? Compared to other children of similar age, how would you describe your child s overall behavior and ability to listen and follow directions? What are some of your child s favorite activities and/or toys? How would you describe your child with respect to strengths/weaknesses, likes/dislikes, personality, etc.:

7 8. DEVELOPMENT OF STUTTERING: Is there a family history of stuttering? If yes, who? Please provide more information about severity and whether this individual grew out of it, made gains through therapy, or still stutters: How long has your child been stuttering? Please state age at which it was first noticed: Do you recall any specific circumstances surrounding the onset of stuttering? If yes, please explain: What were the first signs of stuttering? Since the onset of stuttering, have there been any change in stuttering symptoms Check those that apply: * Increase or decrease in the number of repetitions per word * Change in the amount of force used Increased? Decreased? * Increase or decrease in amount of stuttering * Increase or decrease in length of block * Periods of no stuttering * More precise in speech attempts * Lowered or raised voice (volume) * Slower or quicker speech rate * Change in location of force when stuttering * Looking away from the listener Please elaborate on any of the above the profile of your child: Were there any periods (weeks/months) when the stuttering disappeared? When?

8 Where there any periods (weeks/months) when stuttering increased? Can you provide any explanations for these worse periods? Is child aware of the stuttering? If so, what comments has he/she made about it? Has there been any avoidance of speaking because of stuttering? Give examples, if any: 9. CURRENT STUTTERING: Please check any of the following that currently occur your child stutters: Repeating part of a word Saying uh uh or something similar Pausing in the middle of words Holding his/her breath Inhaling irregularly Exhaling irregularly Gasping Delay in starting words Revisions of words Repeating whole words Repeating portions of words Repeating single sounds Prolonging sounds Failing to complete words Substituting words Silent stutters or blocks Closing his/her eyes Pressing his/her lips together Other (please describe): Other (please describe): Is child s speech the same in all situations? When is it best?: When is it worst? Are there any situations that are particularly difficult? if so, describe: List any situations that never cause difficulty:

9 Does child seem to experience tension associated with any of the following when he/she stutters? lips shoulders tongue chest jaw stomach Answer yes or no to the following as they apply to your child s stuttering: Does he/she stutter when he/she Talks to children? Says own name? Answer direct questions? Talks to adults or teachers? Use new words that are unfamiliar? Use the telephone? Read out loud? Recite memorized material? Are speaking to an authority figure? Ask questions? Talk to strangers? Speak when tired? Speak when excited? Speak when he/she feels rushed? Talks to family members? Talks to friends? Do you know any other stutterers? Describe your relationship: Do you feel that stuttering interferes with your child s daily life? Social relationships? Success at school? How? Which of the following behaviors best describes how your child seems to cope with stuttering daily? Check all that apply: Avoidance of situations. Avoidance of telephone. Use of verbal interjections (um, uh) or filler words (well, so like) Use of body movements to get through difficult situations Use of facial grimaces (e.g. eye closure, lip pursing, knee slapping) to get through difficult situations Of the behaviors described above, which does he/she use the most frequently? In what way do you feel it helps? Any other tricks child seems to use to get through blocks Is stuttering beginning to affect child s life? How have others reacted to the stuttering? Does the child have any other Speech/Language issues? Please elaborate:

10 How have you, as parents, attempt to deal with the problem? 10. CONCERNS: In your own words, please describe your concerns about your child with regard to speech and language abilities. What do you hope to learn from this evaluation? If there is additional information which you feel will help me to understand your child better, please describe: Other comments: Parent/Guardian Signature Date

11 VIDEOTAPING Under some circumstances I am willing to videotape Oral-Motor/Feeding/Speech assessment (not language) if parents or schools request. This is done in lieu of a written report and you will need to provide the camera equipment and do the filming. If you prefer a video assessment to a written report, please indicate your wishes in the space provided and sign your written consent (see below): I prefer for the Oral-Motor/Feeding/Speech Evaluation to be presented: 1. In the form of a videotape or CD (circle preference) 2. In the form of a detailed, written report: I give my permission for the Evaluation or subsequent therapy sessions to be videotaped for (please check all that apply): a. educational purposes: yes no b. in lieu of a written report: yes no c. to provide parents/other professionals with a better idea of what goes on in therapy in the event that the child works better without them in the room: yes no d. You may not videotape my child for any purpose: I give my permission for you to audio tape my child for the purpose of better language, articulation or flueny sampling and/or to achieve baselines for therapy: yes no Parent Signature Date