Infant/pediatric (0-5) Speech Pathology History Form Page 2
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3Infant/Early Childhood (0-5 years) SLP History Form page 2/3 Name: ___________________________
Motoric Development: Normal Development for head control (3-4 months), sitting (6-7 months), walking
(12-15 months), toilet training (2½-3½ years), & eating Delayed or Later Development (Complete All Below)
Age achieved/further information
YES
NO
Head support:
____________________________
YES
NO
Unsupported sitting:
____________________________
YES
NO
Walking without holding on:
____________________________
YES
NO
Trained for bowel/bladder:
____________________________
YES
NO
Does he/she have any accidents?
____________________________
YES
NO
Does child have difficulty sucking?
____________________________
YES
NO
Does child have difficulty chewing?
____________________________
YES
NO
Does child drool?
____________________________
Current diet: Regular
Cut up foods
Baby Food stage______
other_________
Speech – Language Development: Normal Development for babbling (3-6 months), first words (12-16
months), & combining words phrases/sentences (2-3 years) Delayed/Later Development (Complete All Below)
Age achieved / further information
YES
NO
Babble:
____________________________
YES
NO
Meaningful Words:
____________________________
YES
NO
Combine two to three words:
____________________________
Current communication: Verbal/sentence level Verbal/few words
Vocalizing
Gesturing ASL
Does your child understand directions: YES NO Comments: _________________________________
Has your child received:
Name/Location/Phone number of therapist
Frequency of treatment
YES NO
Physical Therapy:
__________________________________ ______________________
Occupational Therapy YES NO __________________________________ ______________________
YES NO
Speech Therapy
__________________________________ ______________________
Psychology/Psychiatric YES NO ___________________________________ _______________________
Services
Medical History: Does the child have any of the following (past or present):
YES NO
YES NO
ADD/ADHD
Learning Disability
YES NO
YES NO
Allergies
Heart Problems
YES NO
Circle/describe: seasonal food medication
High Fevers
YES NO
YES NO
Asthma
Diabetes
YES NO
YES NO
Cancer
Epilepsy
YES NO
YES NO
Chicken Pox
Hepatitis
YES NO
YES NO
Colds
HIV Positive/ AIDS
Ear Infections YES NO
YES NO
Respiratory Disease
Gastric Reflux YES NO
YES NO
Seizures
YES NO
YES NO
Hearing Loss
Mental Retardation
Cerebral Palsy YES NO
Pneumonia/Bronchitis YES NO
Developmental Delays YES NO
YES NO
Tracheostomy Tube
Please list any other medical history including surgeries/medications (and reason for medication):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Speech Pathologist’s notes: ____________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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