Essence of Communication

Pediatric History

The information provided on this form is confidential. It is used to appropriately prepare for the evaluation.

At the time of the evaluation we may ask for clarification or discuss any further information

***Please fill out each line to the best of your knowledge or put N/A if not relevant***

Personal Information:

Child’s Name: ______DOB: ______Age: ______

Person completing form: ______Relationship: ______

Referral Information:

Describe your and/ or other’s concerns about your child’s speech-language / communication / learning skills: ______

______

Referral Source(s): *** This information is required***

Primary Healthcare Provider: ______Phone #: ______

Practice Name: ______Specialty: ______

*** A copy of the evaluation will be sent to the primary healthcare provider, even if they did not make the initial referral ***

Referring Healthcare Provider:

___ Same as Primary

___ Other Healthcare provider (ex: ENT, Neurologist, etc)

Name: ______Phone #: ______

Practice Name: ______Specialty: ______

___ Not referred by a Healthcare provider (ex: school SLP, tutor, friend, etc)

Name: ______Phone #: ______

Association to client: ______

Past and/or Current Speech-Language Services:

___ Early Intervention

___ In School (IEP and/or 504 Plan and/or RTI):

Grade(s): ______

Still receiving? ___ Yes ___ No why stopped? ______

___Other private practice or institution (hospital, clinic, center, etc):

Name of place: ______Phone: ______

Provider’s Name: ______

Dates of service: ______

Status of these services: ___ Discontinued

___ Continue in addition to services at Essence of Communication

*** We will need copies of recent reports, IEPs, etc from all past and current providers prior to the evaluation***

If you are unable to provide the reports we require a signed release of information and will request the records.

Family History

Mother’s Name: ______Father’s Name: ______

(If applicable)

Co-mother’s Name: ______Co-father’s Name: ______

Child currently lives with:

___ both parents in same home

___ shared living in different homes between parents

___ a single parent (other parent not involved with child) ___Mother ___Father

___ Other (Guardian, family member, foster care) (Please describe relationship): ______

Is the child adopted? _____ At what age: ______Outside the US, where? ______

Siblings:

Name: ______Age: ______Sex: ______

Name: ______Age: ______Sex: ______

Name: ______Age: ______Sex: ______

Name: ______Age: ______Sex: ______

Language:

What is the native language spoken in the home? ______

What other language(s) are spoken in the home? ______

If English is not the primary language spoken in the home what is the preferred language the child speak? ______

Family History of any Speech – Language / Learning / Developmental Problems?

Yes / Describe
Mother
Father
Siblings
Maternal family side
Paternal family side

Describe any other family history that you feel is important: ______

Goals

Please provide us with your primary goals and expectations for us to keep in mind during the evaluation and therapy processes.

Developmental History

Prenatal History:

Overall health of mother during pregnancy: ___Good ___Poor ___ Unknown

(please check below all that apply)

Yes / Condition / Describe including treatment, medications, etc
Anemia
Bleeding
Hypertension
Rh incompatibility
Serious viral infections
Severe nausea & vomiting
Substance Abuse
Toxemia
Other

Length of pregnancy: ______weeks. If less than 40 weeks please state why: ______

______

Describe any other complications during pregnancy: ______

______

Delivery:

____Vaginal Length of labor ______Induced? Y / N Drug(s): ______

Please describe delivery including any complications: ______

____C-Section Why? ______

Drugs: ______

Complications:______

Birth:

Apgar Scores: ______Birth weight: ______Length: ______

Please indicate if any of the following were present at birth:

Yes / Condition / Describe including treatments, medications, etc
Blood sugars abnormal
Blueness
Breach
Cord around neck
Difficulty breathing
Required oxygen
Injury
Jaundice
Other

Neonatal Care:

Was in a Special Care Nursery (SCN) or NICU? ______If yes, how long? ______

Why? ______

Care in SCN/NICU: Please describe any concerns/difficulties while in the SCN/NICU (latching on, feeding problems, reflux, difficulty calming, etc): ______

______

Were therapy services and/or medical follow-up recommended at discharge? Yes / No If so what? ______

______

Development:

Feeding: ___Breast Fed How long? ______Easy ___Difficult: ______

___Bottle Fed How long? ______Easy ___Difficult: ______

___Other: ___N-G Tube ___PEG Why? ______

How Long? ______Comments: ______

___Reflux: How long? ______How managed?: ______

Eating: When did the child start eating? Soft solid foods: ______Chew solid foods: ______

When did the child start drinking from? Sipper cup: ______Regular cup: ______

Habits (picky eater, typical, etc) describe: ______

Diet (gluten free, restrictions, textures, etc) describe: ______

Oral-Motor: ___ Sucks: Thumb / Finger / Pacifier / Objects ____History of ___Currently does

Describe: ______

___ Oral Habits: Bites fingernails / chews clothing / other ____History of ___Currently does

Describe: ______

Motor: (please record age when first observed):

Rolling over: ______Sitting unsupported: ______Crawling: ______Walking: ______

Is handedness established? Y / N Preference: ___Right ___Left

Body coordination concerns? Y /N Describe: ______

Toilet Training (daytime only): Completed? Y / N Age: ______Easy ___Difficult

Speech:

Babbling (combined syllables such as “baba, bobo”, etc when they were a baby): Y / N

Describe: ______

Age of first words: ______What were the first words? ______

Age of word combinations: ______What were the combinations? ______

Did speech start and then stop? ______What age? ______

Special Programs / Other Therapies: Please list any additional services your child has or is receiving, include the provider’s name if possible

(ex: OT, PT, Educational / Tutoring, Autism, Counseling, Horse, Adaptive PE, Vision, Hearing, etc)

Through the School Outside of school

Medical History

***Please provide as much detail as possible***

Medical Conditions / Illnesses / Injuries:

Condition / Age / Describe
Attention Deficit Disorder
Asthma
Autism / PDD
Brain Injury
Chronic upper respiratory infections
Encephalitis
High Fever
Meningitis
Seizures
Surgery other than tubes in ears or Tonsillectomy
Syndromes
Trauma
Other

Upper Respiratory History and Current Status:

Ear Infections: Frequency: ______Severity: ______Eardrum rupture? Y / N

PE Tubes: Y / N ENT: ______

Surgery Date(s): ______

Upper Respiratory Infections: Frequency: ______Describe: ______

Tonsillectomy/Adenoidectomy: ENT: ______

Surgery Date(s): ______

Frequent nebulizer use: ______

History of oxygen use: ______

Sleep patterns:

___Sleeps through the night without waking, except toileting

___Wakes frequently during the night. Reasons: ______

___ Snores

Number of hours sleeps at night continuously: ______

Allergies: Please check all that they are allergic to and describe response to allergens:

___Foods ___Nuts ___Milk ___Latex ___Medications ___Environmental ___Other: ______

Describe: ______

______

Vision and Hearing:

Yes / Date / Where / Results / Concerns
Hearing Tested
Vision Tested

Current Medications: Please list current medications and reason for taking

Current Level of Functioning

Communication:

How does your child currently communicate? (ex: Points, grunts, whines, gestures, talks in sentences, etc):

______

How does your child feel about his/her communication skills (include behaviors, verbal remarks, etc)?

______

How do others respond to your child’s communication skills?

Parents: ______

Siblings: ______

Peers: ______

Others: ______

Learning / Academics:

Current School: ______Grade:______

Describe any academic concerns you may have: ______

Has your child been retained a grade? ____ What grade?: _____ Why? ______

Does your child have difficulty learning new information?______

Does your child have difficulty concentrating or attending to tasks? ______

If your child does not attend preschool/school, do they attend day care or other learning environments? ______

If so: Where? ______Frequency: ______

Sensory:

Describe any sensory issues your child may have, especially regarding touch, light, smells, sounds, etc: ______

______

How are sensory issues managed? ______

Social / Play: Describe your child’s social and play skills: ______

______

Describe any concerns you have regarding your child’s social / play skills: ______

______

Describe any extra curricular activities (e.g., soccer, piano, church, etc): ______

Behavior: Describe your child’s overall behavior: ______

______

Describe your child’s personality: ______

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