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NORTHEASTERN UNIVERSITY 30 Leon Street 503 Behrakis Health Science Center

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NORTHEASTERN UNIVERSITY 30 Leon Street 503 Behrakis Health Science Center
NORTHEASTERN UNIVERSITY
Speech, Language, and Hearing Center
30 Leon Street
503 Behrakis Health Science Center
Boston, MA 02115
Ph: (617) 373-2492
Fx: (617) 373-8756
Child Intake Form
(To be completed by the parent of guardian and returned to the clinic)
TODAY’S DATE:
Name of child to be evaluated:
Sex:
Address:
Phone: (H)
(W)
Email:
Date of Birth:
Age:
Grade:
Referred by:
Who should be contacted to schedule an appointment:
Other Languages Spoken:
Language Dominance:
FATHER’S NAME:
Address:
Phone: (H)
(W)
Email:
Date of Birth:
Age:
Occupation:
Level of Education Completed:
MOTHER’S NAME:
Address:
Phone: (H)
(W)
Email:
Date of Birth:
Age:
Occupation:
Level of Education Completed:
Page 1 of 9
NAMES OF BROTHERS AND SISTERS:
AGE:
GRADE:
LEARNING/SPEECH PROBLEMS?
Is there anyone else living in the home?
Has there been a history of divorce or separation in this family?
Description of speech and/or hearing problem
1. Please describe your child’s speech or hearing difficulty.
2. When and how did the problem begin?
3. Who was the first person to notice the problem?
4. Does the child feel he / she has a problem?
5. Describe any changes in the problem since it began.
Developmental History
Pregnancy and Birth: (questions refer to the child to be evaluated)
How would you describe the mother’s health?
Before pregnancy?
During pregnancy?
After pregnancy?
2. Did the mother experience any of the following during pregnancy?
Approximately when during pregnancy?
German Measles
High Fever
Kidney Infection
Page 2 of 9
Anemia
Bleeding
Swelling legs and/or arms
X-rays
Accidents
Drugs
Other:
3. Was the child full term or premature? (check one)
Full term
Premature
If premature: How many weeks?
4. Labor:
More than 10 hours
Birth Weight:
Difficult
Less than 2 hours
5. Hospital where child was delivered:
6. Attending physician:
7. Delivery:
Normal
Cesarean
Breech
Forceps
Anesthesia
Other (describe)
8. Was breathing difficult to initiate in this child?
9. Did the child present any of the following problems at birth?
Bruises/abnormalities in the head region
Need for oxygen
RH incompatibility
Feeding problems
Cerebral Palsy
Blood transfusions
Cleft lip / palate
Other (describe below:)
10. Did the child receive any special medication or treatment at birth?
11. Is there any history of miscarriage or still birth?
Page 3 of 9
Developmental Milestones
1. Please check if the infant:
Resisted being held
Cried excessively
Was responsive to affection
2. Please indicate the approximate age when the following first occurred:
held head up
fed self with spoon
sat up
achieved bladder control
crawled
achieved bowel control
walked
stopped wetting at night
first babbled
said first words
first combined words
3. Which hand does the child prefer to use?
right
left
4. Do you feel that the child has any of the following traits?
Describe:
highly active
eating problems
sleeping problems
toilet-training problems
problems playing with other children
discipline problem
unusual fears
nervous habits
strange behaviors that trouble you
awkwardness and lack of coordination
dental problems
bed wetting
other
Health Record
1. Describe the child’s general health.
2. Is the child currently under medical treatment or medication?
Page 4 of 9
3. Who is your family physician or pediatrician?
Name:
Address:
Phone:
4. List and describe any hospitalization, operations, or accidents.
5. Please indicate if the child has had any of the following:
mumps
convulsions
fainting spells
measles
tuberculosis
ear aches/infections
chicken pox
pneumonia
allergies
whooping cough
frequent laryngitis
meningitis
scarlet fever
tonsillitis
freq. sore throat
high fever
frequent colds
other
6. Does the child ever complain about hearing noises (ringing, buzzing, roaring, etc.) in his/her ears?
7. Has the child been exposed to loud sounds (gunfire, heavy machinery, etc.)?
8. Does anyone in the family have a history of any of the following:
Problem:
speech, language problems
hearing problems
brain damage
mental retardation
cerebral palsy
emotional disturbance/mental illness
chronic illness (Please Specify Type:
Relationship:
)
Educational History
1.
Level
Attended (check if ‘yes’)
Dates
nursery school, day-care
Kindergarten
1st grade
2.
Has the child been promoted regularly?
3.
Is the child in a special class?
Page 5 of 9
4.
Is the child receiving tutoring in any subject area?
1. What school does the child attend now?
Name:
Address:
Phone:
Grade:
Teacher’s Name:
Principal’s Name:
6.
What is the child’s attitude toward school?
7.
What is the child’s favorite school subject or activity?
What subject / activity does the child complain about the most?
8.
Please check any of the following that you feel are true of this child.
discipline problem
receives preferential seating
difficulty learning to read
speech/hearing problem affects school work
difficulty learning to write
complains of being teased by classmates about
short attention span
his/her speech
Speech and Language Development
1. At what age did the child first put words together meaningfully?
2. Who was the child’s primary speech model?
3. Has the child been exposed to more than one language?
4. Did the child stop talking or making sounds at some time?
If so, at what age?
5. Have you always had difficulty understanding what the child is saying?
6. Which member of your household understands the child’s speech the best?
Page 6 of 9
7. Who has the most difficulty understanding the child?
8. Please check any of the following characteristics that are true of the child’s speech NOW
out of breath while talking
drools while he talking
overly tense while talking
holds breath while talking
tries to talk faster than he/she can think
more difficulty than others thinking what to say
hoarse voice
abnormally high pitched voice
sounds like he/she is talking through his/her nose
uses gestures instead of words to communicate
uses single words only
always talks too softly
always talks too loudly
doesn’t talk, just makes grunting noises
seems to stare at people when they talk
won’t answer you if he/she can’t see you talk to him/her
often refuses to talk to people
9. Does this child?
a. hear when you call?
b. hear the telephone?
c. understand what you say?
d. follow simple commands or requests?
10. Does this child usually ask for things by (please check one)
making sounds
using appropriate words
using phrases or sentences
pointing or gesturing
getting a brother or sister to get it for him/her
11. Have you ever felt that this child had difficulty hearing?
a. How old was the child when you first questioned his/her ability to hear?
Page 7 of 9
b. Has he/she ever had a hearing test?
When?
Where?
12. Does this child wear a hearing aid?
a. Approximately when was it purchased?
b. What is the make and model number?
c. Who is your hearing aid dealer?
Address:
d. Does this aid seem to be operating properly at this time?
13. Has anything been done to improve your child’s speech?
Did the speech appear to improve?
14. Have you had this child evaluated by any other clinic?
Name of Clinic:
Address of Clinic:
Date of Evaluation:
Findings:
15. Has this child received speech therapy previous to this time?
PLACE:
DATES:
THERAPIST:
May we have your permission to request information about the evaluation and/or therapy mentioned above to
assist us in our evaluation of your present difficulty?
If so, please fill out one of the attached “AUTHORIZATION FOR RELEASE OF INFORMATION” forms. If
the evaluation and therapy took place in more than one place, please fill out one form for each setting.
16. To whom would you wish our reports to be sent?
Page 8 of 9
Name of person filling out this form:
Date this form was filled out:
Relationship to the child:
Who suggested that you request an evaluation at Northeastern?
Name:
Position:
Are there any limitations on your schedule that would make it impossible for you to come for an evaluation on
any specific day?
If you have any other information which you feel would be helpful to us in preparing for your evaluation, please
write it in the space provided below.
Thank you for your time in filling out this form.
Page 9 of 9
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