Health And Developmental History Initial Assessment Form Page 4
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4SPEECH/LANGUAGE
Did your child babble as a baby?
Yes
No
At approximately what age did your child use single words? ___________________
At approximately what age did your child use sentences? _____________________
Did your child acquire speech and then stop talking?
Yes
No
Does your child have a history of frequent ear infections?
Yes
No
Can your child make his/her wants and needs known?
Yes
No
Voice
Does your child have:
An unusually loud voice?
Yes
No
Hoarse?
Yes
No
Breathy?
Yes
No
Monotonous?
Yes
No
Stuttering
Does your child repeat sounds in words?
Yes
No
Does your child repeat sounds in phrases?
Yes
No
Does your child prolong sounds in words?
Yes
No
Does your child tend to get stuck on words?
Yes
No
Frequency of occurrence: ____________________ When: __________________________________________
Additional information or expansions you would like to make regarding speech and language: _____________
__________________________________________________________________________________________
__________________________________________________________________________________________
PERSONALITY
Child’s temperament: ________________________________________________________________________
Child’s self-image: ___________________________________________________________________________
Child’s attitude toward school: ________________________________________________________________
Child’s attention span: _______________________________________________________________________
Any particular concerns the child has: ___________________________________________________________
SOCIAL/EMOTIONAL DEVELOPMENT
Does your child prefer to play alone or with other children? _________________________________________
Does your child prefer to play with children his age, older, or younger? ________________________________
Relationship with siblings: ____________________________________________________________________
Relationship with peers: ______________________________________________________________________
Is there anything at home or school that might be upsetting the child (recent/frequent moves, deaths, changes
in the family, stress, etc)? _____________________________________________________________________
Social/emotional concerns: _______________________________ Onset: ______________________________
Has the child received counseling?
Yes
No
Explain: _________________________________________
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