Confidential Speech and Language History
*Please complete and return prior to scheduled appointment (scan/e-mail, via regular mail).
Date of Birth: Age: Sex:
Parents/Legal Guardian 1 Parents/Legal Guardian 2
Home Phone: Home Phone:
Cell Phone: Cell Phone:
Work Phone: Work Phone:
ALLERGIES: Food (Please list):
Latex: Yes No
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?
Is your child currently attending school/daycare? Yes No
If so, where?
Home School Public School Private School
Does your child receive any services? IFSP IEP 504 Accomodation Plan
Does your child receive any modifications or accomodations? Please describe.
Biological Child Adopted Child
If adopted, from where and at what age:
Please indicate any conditions that applied to the mother during this pregnancy:
Rh negative High Blood Pressure Virus/Infections
Did the mother take any medications, drugs or alcohol during this pregnancy?
Yes No If so, what?
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
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?
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:
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
Not making speech sounds Not imitating sounds
Difficulty saying speech sounds--examples:
Speech is difficult to understand Speech sounds distorted (lisp)
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
Repeating sounds Repeating words Avoids speaking situations
Demonstrates frustration Seems to get stuck
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
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:
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
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
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
Prefers to be alone
Difficulty sharing or cooperating with others
Does not demonstrate pretend/imaginary play
Does not use toys appropriately/symbolically
Easily distracted Frequent tantrums Aggressive behaviors
Difficulty with changes in routine Demonstrates separation anxiety
Easily frustrated Unusual sleeping/eating patterns Cries a lot
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
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
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
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.
Favorite Places to go/activities:
Favorite Movie/TV show/Characters:
Favorite Food/Drink (reinforce):
Sports/Activities involved in:
Any Musical Instruments Played or Hobbies:
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 firstname.lastname@example.org for a prompt response.