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Family and Patient Profile

Please take a moment to complete the form below. This information will enhance our ability to assist your family. The information collected is completely confidential and will not be released to any other party without your expressed permission. Collecting this information will save time should you decide to use our clinic to provide a consultation or service for your family.

To request that a copy of this report be sent to your E-mail address, click “send me a copy” at the end of the report.

If you are filling this form out for multiple children please check here. Yes No

If you checked "Yes", the section regarding "Patient Medical History" can be repeated for other children.

I. General Information & Family Background

Mother's Name
 
Mother's Birth date
  / / (mm/dd/yyyy)
Mother's Occupation
 

Father's Name
 
Father's Birthdate
  / / (mm/dd/yyyy)
Father's Occupation
 

Children's Names
 
Name of Child as patient
 
Child's Birthdate
  / / (mm/dd/yyyy)

Marital Status:

Single
 
Married
 
Separated - Custody
 
Divorced -Custody
 


Mother's address
:

Street/Apartment
 
City
 
State
 
ZIP
 
Home Phone
 
Work Phone
 
Fax
 
Cell
 
E-Mail
 


Father's address: (supply information only if different than mother)

Street/Apartment
 
City
 
State
 
ZIP
 
Home Phone
 
Work Phone
 
Fax
 
Cell
 
E-Mail
 

 

Other Pertinent Information:

Primary Language Spoken at Home
 
Secondary Language Spoken at Home
 
Mother's Ethnicity
 
Father's Ethnicity
 
If your child is adopted
what is their Ethnicity
 
Is there a family history of speech, language, or learning problems (Mother's or Father's family)?
 
In case of an emergency who should be called?
   
First:
 
Second:
 



II. Patient Medical History

Prenatal and Birth History:
 
Mother's general health during pregnancy (illness, accidents, medication, etc.)
 
Length of pregnancy
 
Complications during or after delivery:
  Yes No
If yes, please describe
 
     
General condition of baby
 
Birth weight
 
     
Has your child had any serious accidents, injuries, or illnesses
  Yes No
If yes, please describe:
 
     
Does your child have a history of allergies, asthma, colds, ear or other respiratory infections?
  Yes No
If yes, please describe:
 
     
Did your child have a problem:    
Feeding:
  Yes No
Swallowing:
  Yes No
Drooling:
  Yes No
     
Has your child had any hearing evaluations?   Yes No
Please provide date(s)
  / / (mm/dd/yyyy)
Please provide date(s)
  / / (mm/dd/yyyy)
Please provide date(s)
  / / (mm/dd/yyyy)
     
Regardless of any test, do you suspect a hearing problem, and if so, why?  
     
Is your child on any medications?
  Yes No
If yes, please describe:
 
     
Pediatrician's Name
 
Phone Number
 
     
Can we contact your doctor?
  Yes No
   

Has your Pediatrician suspected or diagnosed your child with a Speech/Language impairment?

  Yes No
     
Please give a brief description
of what was found.
 

Other Medical or Healthcare Professionals, Types and Names:

Name
 
Type
 
Permission to Contact
  Yes No
Phone
 

Name
 
Type
 
Permission to Contact
  Yes No
Phone
 

Name
 
Type
 
Permission to Contact
  Yes No
Phone
 

Please give a brief description of services provided by other professionals (e.g. OT, PT, psychologist), past or current.

 

III. Educational History:

Does your child attend any daycare, preschool, or school? Yes No


Name of school/agency and contact name:

School/Agency
 
Contact
 
Phone
 
Permission to Contact
  Yes No
     
Are there any types of issues noted in your child’s academic work?
  Yes No
     
Has your child ever had a formal Speech/Language Evaluation or Assessment ?
  Yes No  
 (If yes, please mail a copy of this document)
     
     
Please give a brief description of the diagnosis within the document.
 
     
Does your child receive special services as part of his/her school program?
  Yes No
     
If yes, please describe:
 
     


IV. Patient Developmental History

Please provide your child's developmental history.

Sitting
  / (mm/yyyy)
Crawling
  / (mm/yyyy)
Standing
  / (mm/yyyy)
Walking
  / (mm/yyyy)
Babbling
  / (mm/yyyy)
First Word
  / (mm/yyyy)
Two or three word phrases
  / (mm/yyyy)
Simple Sentences
  / (mm/yyyy)

Do your child's fine and gross motor skills
appear appropriate for their age?
Yes No

If no, please describe.



V. Please give a brief history of any medical or learning problems your child has experienced along with the approximate age at which they experience the problem.



VI. We have found that many times it is the parents who identify the first signs of speech and language issues. A parent's "gut feeling" is often very accurate.

As a parent, regardless of whether or not your child has been diagnosed or evaluated for speech/language impairment, please briefly discuss your concerns.
 


Send me a copy of this report via E-mail: Yes No


 
 
 
 

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Phone: 310.856.8528
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