Speech Language & Developmental History

Student Information

Last Name: ______First Name: ______Middle Name:______

Birthdate: ______Grade:______Sex: □ Male □ Female

Race: __Caucasian __African American __ Hispanic or Latino __Asian

__ American Indian or Alaska Native __Native Hawaiian or Other Pacific Islander

__Multiracial __Other

Language(s) spoken: ______

Does your child have a medicaid number?: ______

Home District: ______Attending School: ______

Teacher: ______

Parent/Guardian Information

Name of parent/guardian completing this form: ______

Relationship to child: ______

Date: ______Contact Number(s): ______

Family History

Housing Status: Student lives with □ Mother □ Father □ Both Parents □ Other: ______

•FATHER’S INFORMATION

FATHER’S Name: ______

□ Biological □ Step-Parent □ Adoptive Parent*

Occupation: ______Highest Grade Completed: ______

If adopted * or step-parent, do you have any information on biological parents?

______

Learning or other difficulties in school: ______

• MOTHER’S INFORMATION

MOTHER’S Name: ______

□ Biological □ Step-Parent □ Adoptive Parent *

Occupation: ______Highest Grade Completed: ______

If adopted* or step-parent, do you have any information on biological parents?

______

Learning or other difficulties in school: ______

• ADOPTION INFORMATION (IF APPLICABLE)

Age Child Adopted: ______Adopted From: ______

Were there any medical diagnoses known at adoption: □ Yes □ No

(Please include all known pregnancy/birth information under the Pregnancy and Birth sections 8, 9 & 10.)

•SIBLINGS (IN ORDER OF AGE)

Sibling 1 Name: ______Age: ______

Sibling 2 Name: ______Age: ______

Sibling 3 Name: ______Age: ______

Sibling 4 Name: ______Age: ______

5. Has the child lived with you continuously since birth?

□ Yes □ No* If not*, with whom did the child live? ______

6. There is family history of: / RELATIONSHIP TO CHILD / RELATIONSHIP TO CHILD
Late in learning to speak / □ / Diabetes / □
Poor school achievement, grades repeated, etc / □ / Low Blood Sugar / □
Reading problems / □ / Allergies / □
Speech/Hearing disorder / □ / Heart Problems / □
Mental Retardation / □ / Cancer / □
Seizure disorder / □ / Bone or growth problems / □
7.Unusual family events: / DATE / EXPLANATION
Serious Illness / □
Hospitalizations / □
Death(s) / □
Divorce(s) / □
Frequent Moves / □
Other / □
8.PREGNANCY
Did you have any serious health problems prior to this pregnancy? □ Yes □ No
Explain:
Did you have any health problems during pregnancy? □ Yes □ No
Explain:
Did you have any infections, illnesses, accidents, or injuries during the pregnancy? □ Yes □ No
Explain:
The baby was born: □ On Time □ Early □ Late
If early, by how many weeks?
9.BIRTH
Describe any complications during labor:
Type of Delivery: □ Normal □ Breech □ Forceps □ C-Section
Did you receive medication during labor? □ Yes □ No
Did you receive any anesthesia? □ Yes □ No
10.NEWBORN
What was the birth weight?
Did your newborn experience/need any of the following:
Yes / Please explain:
Oxygen / □ / For how long?
Incubator / □ / For how long?
Birth Defects / □
Jaundice / □
Rh Incompatibility / □
Complications / □
Unusual problems / □
Did your child leave the hospital with you? □ Yes □ No
If no, how long did your child remain in the hospital?
Diagnosis while in the hospital:
11.MILESTONES / AGE / SLOW / AVERAGE / FAST
Roll Over
Sit Alone
Crawl
Walk Alone
Spoke First Word
Put Several Words Together
Toilet Trained
12.LANGUAGE
With regard to language development, which of these apply to your child?
□ Speech Easy to Understand □ Limited Vocabulary □Answers Don’t Make Sense
□ Unclear or Immature Speech □ Responds Slowly □Needs Directions Repeated
□ Difficulty in Relating Ideas □ Short Attention Span
If child has trouble speaking, what is his/her way of communicating?
Has your child ever been enrolled in a speech/language program? Where?
Is your child currently in a speech/language program? Where?
Do you have any concerns about your child’s speech or language? Explain.
13.EMOTIONAL ADJUSTMENT, BEHAVIOR, DISCIPLINE
Which of the following behaviors describe your child?
□ Headaches □ Hyperactivity □ Easily Managed
□ Tires Easily □ Quiet □ Daydreams
□ Withdrawn □ Generally Happy □ Slow to Learn
□ Very Shy □ Bangs Head □ Sucks thumb
□ Will Not Obey □ Aggressive □ Gives Up Easily
□ Jealous □ Stubborn □ Destructive
□ Fall a lot □ Holds Breath □ Repetitive Motions
□ Talkative □ Difficulty Sleeping □ Wet Bed Until Age _____
□ Nightmares □ Doesn’t Like to be Touched □ Tantrums
Behavior not listed that concerns you?
Your child’s best qualities?
What kind of discipline is most effective?
14.SCHOOL HISTORY
Did your child attend preschool? / □ Yes
□ No / Where?: / Age?:
Were there any problems noted at that time?
What schools has your child attended other than in this district?
Does he/she like school? □ Yes □ No
Explain:
What is/are your child’s best school subject(s)?
What is/are your child’s weakest school subject(s)?
Has your child missed a lot of school? □ Yes □ No
Reason:
Did your child repeat a grade? □ Yes □ No
If yes, what grade?
What special help has your child received in the past?
15.MEDICAL HISTORY
YES / AGE/DATE / YES / AGE/DATE
Measles/Mumps/Rubella / □ / Diabetes / □
Sleeping Problems / □ / Chicken Pox / □
Encopresis / □ / Asthma / □
Strep Throat / □ / Frequent Colds / □
Allergies / □ / High Fever / □
Eating Problems / □ / Heart Problems / □
Meningitis / □ / Tonsillitis / □
Seizure Disorder / □ / Pneumonia / □
Bladder/Kidney Problems / □ / Other: / □
Please explain any illnesses checked above:
Is your child on any medication at the present time? □ Yes □ No
Medication / Dosage / Times Taken / Used to Treat / Medication Initiated
Previous Medications:
Medication / Dosage / Times Taken / Used to Treat / Medication Initiated
VISION
Does the child wear glasses? □ Yes □ No
Used for:
Eye Doctor Name: / Phone:
Last exam:
Results of Exam:
HEARING
Does the child have a history of ear infections? □ Yes □ No
History of PE Tubes? / □ Yes □ No / Date Placed: / Date Removed:
Does the child have hearing loss? / □ Yes □ No / □ Left Ear □ Right Ear □Both
Describe Hearing Loss:
ENT Physician: / Phone:
Last Exam:
Results of Exam:
Other examinations – therapy/treatment child has received. Please name specialists who have cared for your child.
TYPE / NAME OF PRACTITIONER / LAST VISIT / RESULTS
Family Practitioner
Dentist
Therapist
Is there anything else you think the school should know about your child that has not been asked for in this report? Please explain.