Infant/pediatric (0-5) Speech Pathology History Form
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_________________________________
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Date of birth: ___________________________
Infant/Early Childhood (0-5 years)
Speech - Language Pathology History Form
Person completing form: □Patient □Spouse □Parent/Guardian □Other-Name____________________________
Mother’s Name: ______________________________
Father’s Name: ________________________________
Address: ____________________________________________________________________________________
Telephone: (home) ______________________ (work) ____________________ (cell) ______________________
Email:______________________________________________________________________________________
Pediatrician (Name/Phone number):______________________________________________________________
Referred by: _________________________________________________________________________________
Reason for evaluation: _________________________________________________________________________
Referral Needed: yes no
Insurance: ______________________________
Policy Number: __________________________
Results will be sent to names/locations listed below if address or faxes are provided
Name
Address or Fax
Phone
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Disclosure of healthcare information will only be provided is authorized by the patient or legal guardian
except for known healthcare providers
___________________________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
___________________________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
I authorize the department to disclose healthcare information to names above. Valid for one year.
Signature of Patient Parent/Guardian _______________________________________ Date: ___________
Printed name of Parent/Guardian: ________________________________________________________________
Pregnancy History: Full Term
Premature __________________ weeks
Please describe any illness/hospitalization of mother during pregnancy: __________________________________
___________________________________________________________________________________________
Drug/alcohol/medication use before or during pregnancy: YES NO If yes, please explain: _____________
___________________________________________________________________________________________
Birth History: Stony Brook University Hospital
Other: ______________________________________
Vaginal delivery
Caesarean delivery; Why? ___________________________________
Delivery:
Was the child one of a multiple birth? Yes _________ No
Birth Weight: ___________________________
YES NO If yes, what kind? ______________________________
Was anesthesia/medication given?
YES NO
Complications / Treatments:
How Long
YES NO
Cord around neck?
_____________________________________________
YES NO
Breathing Problems?
_____________________________________________
YES NO
Transfusions?
_____________________________________________
YES NO
Phototherapy?
_____________________________________________
Other: ______________________________________________________________________________________
Did the baby go home with the mother? YES NO How long after? _________________________________
Speech Pathologist’s notes: ____________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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