Pediatric Speech And Language Intake Form (Page 4 of 5) in pdf

Pediatric Speech And Language Intake Form Page 4

Does/Did your child ever use a pacifier/suck thumb or have an attachment to

any other objects they put in their mouth? Yes / No

_______________________________________________________________________

Are there or have there been any feeding or eating problems (e.g., any

problems with sucking, tolerating specific food textures, swallowing, drooling,

chewing, etc.)? If yes, please describe.

_______________________________________________________________________

From what does your child primarily drink? (e.g. cup, straw, sippy cup, bottle)

_______________________________________________________________________

Describe your child’s attention level. Can your child occupy him or herself

independently?

_______________________________________________________________________

Does your child follow simple directions? Do you have concerns about your

child’s ability to understand what is being said to him/her?

_______________________________________________________________________

What motivates your child most? (favorite toys, places, snacks)

_______________________________________________________________________

How does your child handle frustration?

_______________________________________________________________________

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

Pediatric Speech And Language Intake Form Page 4