Step 1 of 8 12% General InformationChild's Name* Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Name* Mother's Occupation*Mother's Phone*Father's Name* Mother's Email Father's Occupation*Father's Phone*Father's Email Siblings*Ages*Child care arrangements if both parents work*What language is spoken in the home?* Describe the child's speech-language problem:*How does the child usually communicate (gestures, single words, short phrases, sentences)?*When was the problem first noticed?*Has the problem changes since it was first noticed?*Have any other specialists seen the child? If yes indicate the type of specialist, when the child was seen, and the specialist’s conclusions or suggestions.*Are there any other speech, language, or hearing problems in your family? If yes please describe.*Are there any other speech, language, or hearing problems in your family? If yes please describe.*Describe any behavior which is a problem to the parents.*List child’s favorite activities*Please check behaviors that describe your child. looks happy appears sad non-compliant shows self-stimulating behaviors even tempered is affectionate throws/breaks cries frequently very active calm and quiet self-injurious has trouble sleeping friendly/outgoing very independent distractible seems unusually fearful dependent on adults aggressive to others tantrum/screaming Prenatal and Birth HistoryMother's general health during pregnancy (illnesses, accidents, medications, etc.)*Length of Pregnancy*Length of Labor*General Condition*Birth Weight*Type of Delivery*Head firstFeet firstBreechCaesarianWere there any unusual conditions that may have affected the pregnancy or birth?* Medical HistoryProvide the approximate ages at which the child suffered the following illnesses and conditions:Allergies*Asthma*Chicken Pox*Colds*Convulsions*Croup*Dizziness*Draining Ear*Ear Infections*Encephalitis*German Measles*Headaches*High Fever*Influenza*Mastoiditis*Measles*Meningitis*Mumps*Pneumonia*Seizures*Sinusitis*Tinnitus*Tonsilitis*Other* Has the child had any surgeries? If yes, what type and when?*Describe any major accidents or hospitalizations*Is the child taking any medications? Is yes, please identify.*Have there been any negative reactions to medications? If yes, identify.*Has your child's hearing been tested?*Describe child's general health* Developmental HistoryProvide the approximate age at which the child began to do the following activities:Crawl*Sit*Stand*Walk*Feed Self*Dress Self*Is your child toilet trained? Is yes, how old was your child when toilet trained?*Is your child a picky eater?*Does your child show hand dominance?*Does your child fall frequently?*Use single words? (e.g. no, mom, doggie, etc.)*Combine words? (e.g. me go, daddy shoe, etc.)*Name simple objects? (e.g. dog, car, tree, etc.)*Use simple questions? (e.g. Where's doggie?, etc.)*Engage in conversation?* Does your child have difficulty walking, running, or participating in other activities which require small or large muscle coordination?*Are there or have there been any feeding problems (e.., problems with sucking, swallowing, drooling, chewing, etc.)? If yes describe:*Is your child on a special diet?*Does your child have food allergies?*Describe your child's response to sound (e.g., responds to all sounds, responds to loud sounds only, inconsistently responds to sound, etc.):* Education HistorySchool*Grade/Class*Teacher(s)*How is your child doing academically (or pre-academically)?*Does the child receive special services? If yes, describe classroom.*How does the child interact with others? (e.g., shy, aggressive, uncooperative, etc.)*If enrolled for special education services, has an individualized Education Plan (IEP) been developed? If yes, describe the most important goals.*Provide additional information that might be helpful in the evaluation or remediation of the child's problem:*Did your child attend Early Intervention?*YesNoDid your child attend Pre-School?*YesNoDid your child attend Kindergarten?*YesNoAny grades repeated?*SignatureName* Date* Date Format: MM slash DD slash YYYY
