Step 1 of 8 12% General InformationChild's Name* Date of Birth* 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?* Yes No Did your child attend Pre-School?* Yes No Did your child attend Kindergarten?* Yes No Any grades repeated?* SignatureName* Date* MM slash DD slash YYYY
