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?