Metrowest Speech & Language Center
Promoting Face to Face Communication

 Confidential Speech and Language History

Parent Questionairre

 

*Please complete and return prior to scheduled appointment (scan/e-mail, via regular mail).

 

Today's Date:

Last Name:

First Name:

Date of Birth:                           Age:           Sex:

Parents/Legal Guardian 1                                   Parents/Legal Guardian 2

Address:                                                                Address:

 

 

 

 

 

Home Phone:                                                        Home Phone:

Cell Phone:                                                            Cell Phone:

Work Phone:                                                          Work Phone:

 

E-mail:                                                                    E-mail:

 

 

 

 

ALLERGIES:   Food (Please list):

                        Latex:     Yes     No

                        Bees:

                        Seasonal (describe):

                        Environmental:

ALLERGY TREATMENTS:

SPECIAL DIETS:

 

 General Information

 Please list other persons living in the home, their ages and relationship to the child.

 

What languages are spoken in the home? 

 

Does anyone else in your family demonstrate a Learning Disability or Speech and Language Delay/Disorder?   Yes  No  If so, who?

 

Is English your child's first language?  Yes   No

How did you hear about Metrowest Speech & Language Center? 

 

If you were referred to Metrowest Speech & Language Center, who may we thank for your referral?

Name:

Address :

 

 Childcare/Education

 Is your child currently attending school/daycare?    Yes    No

If so, where? 

 

Home School                    Public School                          Private School   

Teacher/Provider Name:

Phone Number:

Town:

Does your child receive any services?     IFSP       IEP       504 Accomodation Plan

Does your child receive any modifications or accomodations?  Please describe.

 

Birth History

 

Biological Child           Adopted Child  

If adopted, from where and at what age:

PRE-NATAL:

Please indicate any conditions that applied to the mother during this pregnancy:

Rh negative     High Blood Pressure    Virus/Infections

extended bedrest     

Other:

Did the mother take any medications, drugs or alcohol during this pregnancy?

Yes     No    If so, what?

PERI-NATAL:

What type of delivery did you have:    Normal Delivery   Induced  Cesarean

Forceps      Single Birth    Multiple Birth      If multiple birth, how many babies?   ________

Indicate any complications with baby:   Injury  

Coloring (yellow/jaundiced or blue)       paralysis      cord around the neck  

needed oxygen           intubated            went to NICU

Any complications with mother immediately following delivery?

 

Duration of pregnancy:    Full-term        Pre-mature

If pre-mature, how many weeks?

How long was hospital stay?

 

Birth weight:     lbs.      oz.    

Normal weight gain & growth with baby?    Yes     No

Any feeding problems?   sucking     swallowing      coughing     gagging   vomiting

 

Medical History

Please identify/list any known diagnoses your child may have:

ADHD/ADD     Apraxia     Asthma     Autism Spectrum Disorder/PDD

Behavioral Difficulties     Brain injury     Bronchitis     Cerebral Palsy

Chromosomal Anomaly   Cleft lip/palate     Convulsions/Seizures

Developmental Delay     Diabetes   Down Syndrome     

Emotional/Mental Health (eg., anxiety, depression)    Encephalitis   

Epilepsy     Frequent Colds     Frequent Ear Infections    

Gastrointestinal Problems (GI)     Genetic Disorder     Hearing Impairment  

Heart Condition     Hydrocephalus     Intellectual Impairment    

Learning Disability/Dyslexia       Motor Planning     Neurological Impairment(s)

Paralysis     Physical Disability      Pneumonia         Respiratory Difficulties   

Respiratory Distress Syndrome (RDS)       Sensory Integration                    

Swallowing Disorders     Visual Impairment

If any of the above were identified please indicate when and where diagnosed:

 

 

 

 

 

 When was the last time your child's hearing was checked?  What were the results?

 

If your child has had a history of frequent ear infections have they received tubes?

Yes    No    If so, when?  

Does your child wear a hearing aid (s) or have a cochlear implant?  Yes    No

Does your child wear corrective lenses or contacts?  Yes   No

If your child has swallowing/feeding disorders are they tube-fed now or have they ever been tube fed?  Yes    No  

Have they had a swallow study done?  Yes    No

If a swallow study was done, when/where?

Results/Recommendations:

 

Does your child have their tonsils?  Yes     No                                                            Does your child have their adnoids? Yes     No

Is your child undergoing any dental/orthodontic work (e.g., braces, palatal expander)?

Yes   No   If yes, please describe:

Since birth, has your child experienced any hospitalizations and/or surgeries?  Please describe briefly:

 

 

 

Please describe any current health concerns/additional information on above diagnoses.

 

 

 

List any current medications (and dosages). 

 

 

 Please indicate if your child has seen or is currently receiving services from the

professionals listed below:

ABA Instructor   AAC Specialist Allergist     Audiologist    

Developmental Pediatrician           Ear/Nose/Throat Doctor (ENT)

Neurologist    Neuropsychologist     Occupational Therapist

Orthodontist        Pediatrician     Physical Therapist            Psychiatrist    

Psychologist     Reading Specialist      Speech-Language Pathologist   Tutoring  

If you indicated yes to any of the above professionals please provide:  the name of the professional, date your child was last seen and frequency/duration if they are seen on a regular basis.

 

 

List any additional providers here: 

 

 

 Developmental Milestones

Please check accomplished skills and indicate age/months:

sat alone                            crawled                                 walked

toilet trained                      pulled off socks                    dress/undress self

babble                                jargon (jabber without real words)

first words                         put words together               finished bottle use

started cup                        finished with pacifier            finger feeds

uses a spoon                     uses utensils

 Inventory of Speech-Language Skills

Please indicate any concerns that apply     

 

ARTICULATION

Not making speech sounds    Not imitating sounds 

Difficulty saying speech sounds--examples:                                           

Speech is difficult to understand                     Speech sounds distorted (lisp)

 Tongue thrust

With a familiar listener describe your child's speech intelligibility:

Speech understood less than 50%   Speech understood 50%

Speech understood 75%    

More difficult to understand by unfamiliar listeners   Yes   No

 

FLUENCY/STUTTERING

Repeating sounds        Repeating words       Avoids speaking situations

Demonstrates frustration     Seems to get stuck

 

VOICE

Pitch is to high or to low for age    Voice is too loud or too soft

Voice has a hoarse or rough quality    Frequent episodes of laryngitis/throat pain

 

LANGUAGE

Non-verbal       Vocabulary is limited        Not putting words together 

Primary means of communication is gesture, leading/pulling, tantrums

Makes grammatical mistakes when speaking in sentences

Has trouble finding the right word/substitutes words

Difficulty expressing ideas     Frustrated when message is not understood

Difficulty re-telling events/story/sequencing steps

Difficulty following directions       Difficulty asking/answering questions

Difficulty with reading comprehension  

Difficulty with higher level semantic skills (e.g., synonyms, antonyms, figurative language)

 

Does your child use Augmentative Alternative Communication (AAC) and/or sign language as a communication modality?  Yes     No

 

If yes, please describe:

 

SOCIAL LANGUAGE

Poor eye contact           Unresponsive/limited response to people

Difficulty initiating conversations/interactions/greetings/social pleasantries

Difficulty taking turns       Difficulty staying on topic to keep conversation going

Difficulty making appropriate comments/polite v. impolite   

Difficulty maintaining appropriate distance from communication partner

Use of language/intent is limited

Speech intonation, rate, pauses are not natural sounding

 

FEEDING

Still uses a bottle            Weak suck                  Difficulty initiating cup drinking  

Messy eater                     Difficulty chewing       Stuffs mouth too full

Sensitive to different textures/colors/temperatures of food

Picky eater                      Gags/coughs/chokes frequently

 

ORAL-MOTOR

Difficulty imitating oral-motor movements (e.g., blowing kisses, sticking out tongue, making raspberries).

Looks like they are groping/trouble making sounds

Demonstrates weakness with tongue, lips, cheeks

 

PLAY SKILLS

Prefers to be alone

Difficulty sharing or cooperating with others

Does not demonstrate pretend/imaginary play

Does not use toys appropriately/symbolically

 

BEHAVIOR

Easily distracted            Frequent tantrums      Aggressive behaviors

Difficulty with changes in routine           Demonstrates separation anxiety

Easily frustrated           Unusual sleeping/eating patterns         Cries a lot

Excessively silly                                                                                       

Demonstrates unsafe behaviors (running away from adults, engaging in dangerous/high risk activities, unaware of street/home safety precautions). 

Covers ears with loud noises    Demonstrates self-injurious behaviors

Trouble starting or stopping activities

 

SCHOOL SKILLS

Difficulty sitting in group learning situations for age appropriate periods of time

Difficulty writing/coloring     Difficulty using scissors/cutting  

Doesn't like paint/glue/messy activities    Trouble completing assignments

Trouble organizing materials  

 

LITERACY SKILLS

Looks at books and pictures           Orients books in the right direction

Turns pages       Scans left to right/top to bottom            Likes to be read to

Difficulty understanding which sound goes with which letter

Recognizes logos (restaurants, stores, food labels)          Enjoys reading

Able to complete books that are age appropriate/grade level

Frustrated with reading      Difficulty understanding what has been read

 

 

Important Information

 

During therapy it is important to have a general understanding of your child's likes/dislikes, everyday vocabulary from their world, activities/items that are motivating and areas of interest. 

Pets (names):

Family/Friend Names:

Favorite Places to go/activities:

Favorite Movie/TV show/Characters:

Favorite Book(s):

Favorite Music/Songs:

Favorite Food/Drink (reinforce):

Sports/Activities involved in:

Any Musical Instruments Played or Hobbies:

Favorite Color:                    

Favorite Games:

Dislikes: ____________________________________________________________________________________

 

Thank you for taking the time to complete this questionnaire.   It will provide the necessary background information and areas of concern to tailor your child's evaluation and/or therapy to meet their individual needs. 

It is helpful to receive this form prior to your child's first appointment to make the most efficient use of your scheduled time.

Please E-Mail/Mail To: 

Melissa Lewi, M.S. Ed., CCC-SLP

Metrowest Speech & Language Center

19 Sherwood Road

Natick, MA  01760

 

 

If you have any questions please do not hesitate to text (508)868-5955 or e-mail melissalewislp@gmail.com for a prompt response.