Child Intake Questionnaire

Date (mm/dd/yyyy)

Name of Child

Birth Date

Name of Person completing this form

Relationship to the Child

Address (Street/City/Postal Code)

Home Phone

Work Phone

Cell Phone

Email

Others living with child
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:

Languages spoken in the home

Family Doctor/Pediatrician

Address of Family Doctor

Phone of Family Doctor

List of agencies involved with your child

Has your child been seen by a Speech-Language Pathologist before?
YesNo

Has anyone in your family had speech, language, reading or learning difficulties?
YesNo

If yes, please describe

Concerns:

What are your main concerns regarding your child’s speech and language?

Developmental History:

Were there any problems during pregnancy?

How many weeks long was the pregnancy?

Were there any problems during birth?

What was the weight at birth?

How old was your child when they sat?

How old was your child when they walked?

Medical History:

Has your child been hospitalized at any time?
YesNo
Details

Does your child have any current medical issues?

Does your child have any allergies?

Does your child take any medications?

Has your child ever had their vision checked?
YesNo

Where and when?

Results?

Does your child have a history of ear infections?
YesNo

How many?

At what age was the first?

Most recent?

Has your child had a hearing test?
YesNo

Where and when?

Results?

Has your child had tubes put in their ears?
YesNo

When?

Who was the surgeon?

Behaviour:

How would you describe your child’s behaviour? (e.g. easy-going, active, aggressive, anxious, etc)

How does your child interact with other children?

Speech and Language Development:

At what age did your child:

Babble

Say first words

Combine 2 words

Talk in sentences

Does your child have any problems understanding language (e.g. following directions or answering questions)?

Have you ever been concerned about stuttering?

Are you concerned about your child’s voice (e.g. hoarse, breathy)?

Education

Does your child attend school?
YesNo

If yes, please list school and grade.

List activities your child is involved with outside of home/school (e.g. play groups, music lessons, swimming, etc.)

Feeding/Oral Motor:

Does your child have any difficulty with:

Chewing
YesNo

Details

Swallowing
YesNo

Details

<>Sucking
YesNo

Details

Drinking
YesNo

Details

Drooling
YesNo

Details

Referral

How did you hear about the Family Speech Clinic?

If you were referred by an individual, do we have your consent to thank them for the referral?