Pediatric Speech And Language Intake Form (Page 2 of 5) in pdf

Pediatric Speech And Language Intake Form Page 2

Please describe your child’s communication (babbling, gestures, single words,

phrases, sentences, conversation)

_______________________________________________________________________

Is your child difficult to understand? If so, are there particular sounds that are

challenging?

_______________________________________________________________________

Is your child aware of his or her problem? If so, how does he or she handle it?

_______________________________________________________________________

Is there any history of speech, language or learning challenges in your family?

_______________________________________________________________________

Prenatal and Birth History:

Length of pregnancy: _________________

Length of labor: __________________

C-section: Yes / No

Birth Weight: _____________________

Please note any unusual conditions that may have affected prenatal

development, including mother’s general health during pregnancy.

_______________________________________________________________________

Medical History:

[ ] Chronic colds/respiratory infections

[ ] Chronic ear infections

[ ] Asthma

[ ] Allergies

[ ] High fever

[ ] Influenza

Is your child taking any medications? If so, please describe duration and

frequency.

_______________________________________________________________________

Courtney T. Gessin, MS, CCC-SLP, Speech-Language Pathologist

Pediatric Speech And Language Intake Form Page 2