AH Intake Questionnaire
Dear Parent or Guardian,
Please save this questionnaire to your personal hard drive. When you have completed the questionnaire, fax it to 206-987-1004 or email it to . Please note that privacy cannot be guaranteed if questionnaires are emailed. In order to expedite scheduling, please include medical and educational reports such as audiograms, IFSP/IEP, and speech evaluations. After we receive the completed questionnaire and requested reports, we will contact you to schedule an Auditory Skills Evaluation. If you have questions regarding this questionnaire, please contact the Childhood Communication Center at 206-987-3853 or email .
Today’s Date: / Click or tap to enter a date. /Background Information
Child’s Name: / First / Middle / Last /
Child’s Birthdate: Enter DOB / Child’s Gender: Choose an item.
Home Address: / Street / City / State / Zip /
Parent/Guardian: Parent’s Name / Parent/Guardian Phone: Phone
Parent/Guardian: Parent’s Name / Parent/Guardian Phone: Phone
Person completing form: Click or tap here to enter text. / Best form of contact:
Choose an item. / Enter best contact phone or email
What languages are used in the home? Click or tap here to enter text.
Would anyone coming to the evaluation, including your child, like an interpreter? Choose an item. / If yes, what language? Language
Why were you referred for this evaluation? Click or tap here to enter text.
What concerns do you have about your child? Click or tap here to enter text.
History
Were there any complications with pregnancy or the child’s birth? / Choose an item. / Was the child born early? / Choose an item. / # of weeks of pregnancy /
Does anyone related to the child have a history of hearing loss or speech, language-learning difficulties?
Choose an item.
Has your child had any serious illnesses or injuries? / Choose an item. / If yes, explain: Click or tap here to enter text.
Does your child have any medical or developmental diagnosis other than hearing loss? / Choose an item. / If yes, explain: Click or tap here to enter text.
Did your child meet developmental communication milestones on time (babbling, words)? / Choose an item. /
Did your child meet developmental motor milestones on time (sitting, crawling, walking)? / Choose an item. /
Do you have any concerns about how your child eats or drinks? / Choose an item. /
Do you have concerns about other areas of development other than hearing loss, speech or language? Click or tap here to enter text.
Hearing
Does your child have a history of ear infections? Choose an item. / Does your child currently have ear tubes? Choose an item.
Is your child’s hearing care managed at Seattle Children’s Hospital? If YES, please skip the following section. If NO, please complete the following section. Choose an item.
Did your child have a hearing screen at birth? Choose an item. / If yes, did your child pass? Choose an item.
Was your child born with hearing loss?
Choose an item. / What age was hearing loss diagnosed?
Age at diagnosis
What is the cause of your child’s hearing loss (if known)? Click or tap here to enter text.
Where was your child’s last hearing test? Click or tap here to enter text. / Date of last hearing test: Click or tap to enter a date.
Hearing Technology History
Does your child use hearing aids? Choose an item. / Does your child have a cochlear implant? Choose an item. / Does your child use an FM system? Choose an item.
Does your child receive hearing aid services at Seattle Children’s? If yes, skip this section. Choose an item.
At what age did your child begin using hearing aids? / Age / Approximately how many hours a day are hearing aids worn? / # of hours /
Play/Social Skills/Communication
How does your child play? Check all that apply:
☐ / Doesn’t play very much with toys
☐ / Explores toys and objects by fitting or grouping them together (stacking, putting in and out of containers)
☐ / Explores toys in expected ways (puts person in car, spoon in cup, doll in bed, etc.)
☐ / Groups or lines up toys
☐ / Prefers to play alone
☐ / Plays side by side and may imitate another child’s play
☐ / Shares and plays cooperatively
What is your child’s favorite toy? Click or tap here to enter text.
Does your child respond when you call their name? / ☐Yes ☐ No ☐ Sometimes ☐ Only when called repeatedly
Which of these gestures and behaviors does your child use? Check all that apply below:
☐ Points ☐ Shakes head for “no” ☐ Reaches with open hand ☐ Pulls you by the hand
☐ Gives ☐ Waves when prompted ☐ Waves spontaneously ☐ Raises arms to be picked up
☐ Nods head for “yes” ☐ Hits/ bites/ kicks/ punches ☐ Screams/yells ☐Throws self on floor
Comments: Click or tap here to enter text.
Expressive Language
How many words can your child say?
☐ Less than 10 / ☐ 10-25 / ☐ 25-50 / ☐ 50-100 / ☐ Too many to count
How does your child communicate now? Check the things your child does most of the time.
☐ Uses behaviors / ☐ Uses gestures / ☐ Uses sign language
☐ Uses single words / ☐ Uses phrases / ☐ Uses speech & signlanguage
☐ Uses sentences / ☐ Holds conversations / ☐ Uses speech only
If your child uses sign language, which system do they use? Choose an item.
Comprehension
How does your child respond to your directions and communication? Check all that apply.
☐ / Needs a physical prompt
☐ / Understands important words (mom, dad, bottle)
☐ / Understands routines (snack time, bath time)
☐ / Follows directions when gestures are used (when you point or hold out your hands to show)
☐ / Follows one part directions (get the ball)
☐ / Follows two part directions (get your cup and your shoes)
☐ / Follows complex directions (throw me the ball after you spin in a circle)
☐ / Understands a conversation
Comments: Click or tap here to enter text.
Speech Sounds
How well can people understand your child’s speech?
Family members understand / Enter percentage % / Familiar listeners understand / Enter percentage %
Unfamiliar listeners understand / Enter percentage%
Please list any sounds your child has difficulty producing: Click or tap here to enter text.
Academics: Please include school evaluations reports (IFSP, IEP, 504) if applicable.
Is your child currently receiving early intervention services? / Choose an item. / What age did early intervention services begin? / Click or tap here to enter text. /
Where does/did your child receive early intervention services? Click or tap here to enter text.
For a child who is 3+ years:
Child’s school: Click or tap here to enter text. / School district:Click or tap here to enter text.
Teachers(s): Click or tap here to enter text. / Speech-Language Pathologist: Click or tap here to enter text.
Does your child us an interpreter in the classroom? Choose an item.
What system of communication is used in the classroom? Click or tap here to enter text.
Does your child have an IEP, or 504 plan? / Choose an item. /
What services does your child receive at school? Check all that apply
☐ None / ☐ Academic (math, reading, behavior, etc): List: Click or tap here to enter text. / ☐ Audiology
☐ Occupational Therapy / ☐ Physical therapy / ☐ Social training / ☐ Speech-language therapy / ☐ Teacher of the Deaf / ☐ Vision
Do you have any of the following concerns for your child who attends school? Check all that apply.
☐ None / ☐ Attention / ☐ Behavior / ☐ Completing tasks / ☐ Learning new skills
☐ Listening / ☐ Memory / ☐ Retaining information / ☐ Self-advocacy / ☐ Social skills
Therapy: Please include all prior evaluation reports for review.
Has your child ever had a speech and language evaluation? Choose an item.
If yes, when? Date of eval / Where? Enter place of evaluation
Has your child received speech-language services outside of school? Choose an item.
If yes, where? Click or tap here to enter text.
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