Initial Speech Evaluation

INITIAL SPEECH EVALUATION

Developmental/Educational History

Student:

Address:

Phone:

Date of Birth: Age:

Form Completed by: Relationship to child:

Brief Statement of Concern:

History

Medical:

Did mother experience any of the following?

Prenatal No complications_____ Complications_____

Explain any complications:

______________________________________________________

Peri-natal

Labor No Complications _____ Complications_____

Explain Complications

______________________________________________________

Gestational Age ___________________

Birth Weight ___________________

Other ______________________________________________________

______________________________________________________

Neonatal No complications ____ Complications____

Explain Complications

______________________________________________________

General Health Good_____ Poor_____

Explanation: ________________________________________________

________________________________________________

Medications N_____ Y____ list___________________________

Special Diet N_____ Y_____list___________________________

Frequent Colds N_____ Y_____

Ear Infections N_____ Y_____Age and Duration: _____________

____________________________________

Allergies N_____ Y_____list___________________________

Hospitalizations N_____ Y_____list___________________________

Illnesses:

Please explain any significant illnesses that your child has had or currently suffers from.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Developmental Milestones: (note whether achieved within normal limits or delayed)

Gross Motor: Sitting WNL_____ Delayed_____age_______

Standing WNL_____ Delayed_____age_______

Crawling WNL_____ Delayed_____age_______

Walking WNL_____ Delayed_____age_______

Speech: Babbling WNL_____ Delayed_____age_______

Words WNL_____ Delayed_____age_______

Combining Words WNL_____ Delayed_____age_______

Sentences WNL_____ Delayed_____age_______

Describe any current concerns you have regarding your child’s speech:

Feeding History:

Breast or Bottle-fed? ____________________No difficulty_____Complications_____

Explain Complications______________________________________________

Can your child drink from a cup? ___________ from a straw?___________

Does your child drool? _____

Does your child have difficulty chewing and/or swallowing certain foods? _______

Explain:________________________________________________________

Describe any specific food-related issues your child may currently have___________

_______________________________________________________________________________________________________________________________________________

Social

Name of School: ________________________________________________

Current Grade Level: ________________________________________________

Hobbies/Interests: ________________________________________________

Socialization with Peers: ________________________________________________

Names and ages of siblings: ________________________________________________

________________________________________________

Educational

Does your child perform well in school? _________________________________

Average Grades_______________________________________________________

Strong Subjects: ______________________________________________________

Weak Subjects: _______________________________________________________

Does your child like school? ______________________________________________

Please add any explanations to above answers in this section:

Please explain any family history of speech and/or hearing problems:

Additional Information:

PLEASE RETURN THIS FORM TO MRS. MANIACE AS SOON AS POSSIBLE.

THANK YOU VERY MUCH FOR YOUR COOPERATION.