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Speech Language History
Deana Lesher
2026-02-03T16:53:55-06:00
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Speech Language History
Client Name
First
Last
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Select…
Male
Female
Parent/Guardian Email
*
Who referred you to Pediatric Connections?
Why were you referred?
Family Information
Client Lives with
Please list all persons living in the home with names and relationship to client – including ages of all children in the home.
Parent #1 Occupation
*
Parent #2 Occupation
Child's Primary Language Spoken at Home
*
Is there a language other than English spoke at home?
Yes
No
Medical History
Was Client Born Premature?
Select…
Yes
No
Unknown
Gestational week
Describe Birth History, including complications:
If client is under 18
Medications
Hearing/Vision Concerns
Has your child had any of the following:
Adenoidectomy
Allergies
Asthma
Breathing Difficulties
Chicken Pox
Colds
Ear Infections
Ear Tubes
Encephalitis
Flu
Head Injury
High Fevers
Measles
Meningitis
Mumps
Scarlet Fever
Seizures
Sinusitis
Sleeping Difficulties
Thumb/Finger Sucking
Tonsillectomy
Tonsillitis
Vision Problems
Tonsillitis: How Often?
Other serious injury/surgery/hospitalizations (age & reason)
Last Hearing Exam
MM slash DD slash YYYY
Results of Hearing Exam
Is client currently under the care of:
Select all that apply
ENT
Neurologist
Occupational Therapist
Physical Therapist
Psychologist
None noted
Other Specialist
Does Client
*
Select all that apply
Choke on foods or liquids
Currently put toys/objects in mouth
Brush teeth/Allow brushing
Drool or pool saliva
None noted
Please tell the approximate age client achieved the following milestones:
Sat Alone
Grasped Crayon/Pencil
Babbled
Said 1st Word
Put 2 words together
Spoke in short sentences
Walked
Toilet Trained
Speech-Langauge Hearing Information
Does the client have a latex allergy?
Yes
No
Your child currently communicates using the primary format of:
Body Language (pointing, gesturing)
Sounds
Words (shoe, doggy, up)
2-4 word sentences
Sentences longer than 4 words
Other (sign language)
What are your child's strengths? What does your child like to do in his/her spare time?
Has your child ever had speech therapy/screening?
Yes
No
Where and when?
(i.e. School district, infant/toddler, private practice)
Was he/she dismissed?
Yes
No
List frequency and length of last service
Is your child aware of or frustrated by any speech/language challenges?
Does your child:
Repeat sounds, words, or phrases over & over
Understand what you are saying
Retrieve/Point to common objects upon request (ball, cup, shoe)
Label items
Follow simple directions (shut the door, get your shoes)
Respond correctly to yes/no questions
espond correctly to who/what/where/why questions
Ask questions
Make eye contact with others when communicating
Imitate others (physically or verbally)
Interact in play with other children
Take turns in simple games and structured activities
Join in on-going activities
Demonstrate appropriate personal space/body proximity with others
Initiate communication with others
Return and initiate greetings
Identify emotions of others by responding appropriately
Interpret body language
Self-regulate when upset or excited
Accept unexpected changes
Cooperative
Restless
Attentive
Willing to try new activities
Easily distracted/short attention span
Plays alone for reasonable length of time
Destructive/aggressive
Separation difficulties
Withdrawn
Easily frustrated/impulsive
Inappropriate behavior
Stubborn
Self-abusive behavior
Flight-risk (runs away)
Educational Information:
If your child is in school, please answer the following
Name of School
Teacher Name
Grade Level
Has your child repeated a grade?
Yes
No
Goals
It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities as it relates to speech and communication:
Goal #1
*
Goal #2
Goal #3
Goal #4
Please state any additional information or comments you feel would be helpful in learning about your child's speech/language behavior:
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