Patient Information
- Full Name: _________________ Date of Birth: _________
- Address: __________________ Phone: ________________
- Primary Care Physician: ________ Insurance: __________
Chief Complaint
- Primary concern: _________________________________
- When did symptoms begin? __________________________
- Previous speech therapy? ☐ Yes ☐ No
- If yes, when and where? _________________________
Medical History
Birth History
- Pregnancy duration: ☐ Full-term ☐ Premature (__ weeks)
- Birth complications: ☐ Yes ☐ No
- Birth weight: _________ APGAR scores: _____________
Developmental History
- Age first words appeared: _________________________
- Age began walking: ______________________________
- Developmental milestones: ☐ On time ☐ Delayed
Medical Conditions
- ☐ Hearing problems
- ☐ Vision problems
- ☐ Seizures
- ☐ Ear infections
- ☐ Feeding difficulties
- ☐ Neurological conditions
- ☐ Genetic disorders
Communication Status
Current Speech Patterns
- Intelligibility: ☐ Good ☐ Fair ☐ Poor
- Voice quality: ☐ Normal ☐ Hoarse ☐ Breathy
- Fluency: ☐ Normal ☐ Stuttering present
Language Skills
- Follows directions: ☐ 1-step ☐ 2-step ☐ Multi-step
- Vocabulary use: ☐ Age appropriate ☐ Limited
- Grammar usage: ☐ Appropriate ☐ Difficulty
Educational/Social History
- Current school/grade: ____________________________
- Special services received: ________________________
- Social interaction concerns: ______________________
Authorization
I certify that the above information is accurate to the best of my knowledge.
Signature: _________________ Date: ________________