Child's First Name
*
Child's Last Name
*
Date of Birth
*
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Month
/
Day
Year
Date
Completed By
Age at time of completion
Evaluation:
Please describe why you are having your child seen for a speech therapy evaluation (e.g. voice, stuttering, expressive language (spoken language), receptive language (understanding of language), articulation, reading difficulty, feeding, oral motor, etc.)
0/200
How does your child usually communicate (e.g., gestures, single words, short phrases, sentences)?
When was the problem first noticed?
Has your child ever been seen by an Audiologist or ENT?
Yes
No
If yes, please explain:
Family History:
History of Speech Disorder:
Yes
No
Type of Speech Disorder (who and what type of disorder):
Speech and Feeding History:
Babbled
Began to eat solid pureed food
Began to eat hard dissolvable foods
Drank from a sippy cup
Combined words
Spoke in sentences
Was there any difficulty feeding your child as a baby/infant?
Yes
No
If yes, please explain:
Does your child:
Drool?
Yes
No
Have difficulty eating a variety of foods?
Yes
No
Have difficulty following directions or routines?
Yes
No
Have difficulty expressing their thoughts clearly?
Yes
No
Pronounce words correctly?
Yes
No
Play appropriately with friends?
Yes
No
If no, please explain:
Speech Sounds and Expressive Language
How much of your child’s speech do unfamiliar listeners understand?
more than 50%
less than 50%
What does your child do when you don’t understand him/her?
When your child retells a story or information from their day, which of these apply?
Not Applicable
it is organized
difficulty remembering/finding words
difficulty remembering details
loses focus
does he/she avoid questions
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