FAMILY AND PATIENT PROFILE

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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

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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