3-18 years old Year Round Application

DEVELOPMENTAL QUESTIONNAIRE

Please Fill Out Completely

How old is your child?

MaleFemale

What are you concerned about?

Parents

Parents are:MarriedNever MarriedSeparatedDivorcedDeceased

Age:

Does family have a history of speech and language difficulties?

YesNo

If yes, please explain:

Siblings

Male or Female?

MaleFemale

Do siblings have a history of speech and language difficulties?

YesNo

If yes, please explain:

At Present

*All children must be up to date on all required immunizations prior to enrollment.

Does your child:

Wear glasses?

YesNo

Have allergies?

YesNo

If yes, please list:

Currently sees a physician for conditions other than regular check-up? Explain:

Takes Medications?

YesNo

Medication

To Treat What?

Frequency

Side Effects

Seems to be emotionally and mentally healthy?

YesNo

If no, explain:

Sees an orthodontist?

YesNo

For what reason?

Have any feeding/swallowing difficulties?

YesNo

Have any feeding/swallowing difficulties?

Birth

Is the child adopted?

YesNo

Length of Pregnancy:

Was the delivery normal?

YesNo

If no, explain:

Was the mother’s health good during the pregnancy?

YesNo

If no, explain:

During pregnancy, did the mother:

Smoke?

YesNo

Drink Alcohol?

YesNo

Use Drugs?

YesNo

Child’s weight/condition at birth:

Development

Does your child have a history of ear infections?

YesNo

If yes: Frequency

At what age did your child reach these developmental milestones?

Sat up alone

Dressed Self

Crawled

Walked Alone

Toilet Trained

Motor coordination is:

ExcellentGoodPoor

Behavior/Discipline

Does your child have playmates in the neighborhood?

YesNo

Seems to be a leader or a follower?

LeaderFollower

Prefer to play with people or things?

PeopleThings

What seems to motivate your child?

What pleases you most about your child’s behavior?

What bothers you most about your child’s behavior?

Method of discipline used?

How often does your child need to be disciplined?

Discipline has been:

StrictLenientInconsistentAdequate

Age of first words:

Age of first sentences:

When did your child’s speech/language first concern you?

How has the family attempted to improve the child’s communication?

What do you think may have caused the problem?

Has your child been seen or evaluated by:

Speech-Language Pathologist?

YesNo

Name:

Agency:

Date:

Developmental Psychologist?

YesNo

Name:

Agency:

Date:

Developmental Pediatrician?

YesNo

Name:

Agency:

Date:

Occupational Therapist?

YesNo

Name:

Agency:

Date:

**PLEASE ATTACH ANY OTHER SPEECH AND LANGUAGE AND/OR MEDICAL REPORTS THAT MAY BE PERTINENT TO YOUR CHILD’S THERAPY HERE AT THE CENTER**

**PLEASE ATTACH DOCUMENTATION OF ALL VACCINATIONS IN THE FORM OF YOUR CHILD’S IMMUNIZATION RECORD OR A SIGNED STATEMENT FROM A MEDICAL DOCTOR**

IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT'S TEST.