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Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Careers
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

Patient History Form Speech

Please fill in the following information to the best of your ability.

Clinic Location *

Patient's Legal Name *

Preferred Name *

Date of Birth *

Age *

Sex *

Male
Female
Other

Address *

Address Line 1

City

State

Zip Code

Telephone *

Person Completing This Form *

Relationship to Patient *

1. Guardian 1's Name / Age *

First

Last

1. Guardian 1's Address *

Address Line 1

City

State

Zip Code

1. Who lives in the home with the child? *

Lives with Patient
Spends time with patient
Has legal custody of patient

2. Guardian 2's Name / Age

First

Last

Guardian 2's Address

Address Line 1

City

State

Zip Code

2. Who lives in the home with the child?

Lives with Patient
Spends time with patient
Has legal custody of patient

Guardian 3's Name / Age

First

Last

Guardian 3's Address

Address Line 1

City

State

Zip Code

3. Who lives in the home with the child?

Lives with Patient
Spends time with patient
Has legal custody of patient

Has this patient (or anyone living in their home) tested positive for COVID-19 in the past 2 weeks? *

Yes
No

Who referred you for this evaluation? *

Self
Pediatrician/Doctor
Other

Other

Patient's Primary Doctor *

Doctor Address

Address Line 1

City

State

Birth History

Please check if birth history information is unknown to you and proceed to next section *

Please check if birth history information is unknown to you and proceed to next section

Pregnancy *

Normal
Abnormal / Complications

Explain

Length of Pregnancy *

Premature *

Yes
No

Birth weight *

Delivery was *

Vagical
C-Section
Emergency C-Section

List any complications at delivery? *

Did the patient experience any complications immediately following birth? *

No
Yes

Explain:

Did the patient pass their newborn hearing screening? *

Yes
No

Developmental History

Please check if developmental history information is unknown to you and proceed to next section *

Please check if developmental history information is unknown to you and proceed to next section

In early childhood, did the patient have any feeding/swallowing difficulties (such as poor control of sucking, food allergies, digestive difficulties, difficulty breastfeeding, regurgitation of food frequently)? *

Yes
No

If yes, please describe

Please provide the ages of development for the following developmental and speech milestones (please put N/A if patient has not met milestone yet):

Sitting unsupported/Walking *

First

Last

Eating solid food / Self-feeding *

First

Last

Crawling / Self-dressing *

First

Last

Standing alone / Bladder-Bower control *

First

Last

Babbling / First Words *

First

Last

Putting Two Words Together / Using 3 Word Sentences *

First

Last

Do you feel like the patient was delayed or had difficulty in the development of these behaviors? *

Yes
No

If yes, please explain:

SOCIAL/EDUCATIONAL HISTORY

Who lives in the home with the patient? *

List all siblings and/or children living in the home from oldest to youngest:*

Name | Age | Relationship to Patient | Grade in School | Lives with the patient? (Yes/No/Sometimes)

Name | Age | Relationship to Patient | Grade in School | Lives with the patient? (Yes/No/Sometimes) *

Does a blood relative of the patient have any speech, language, or hearing problems? *

Yes
No

Has the patient received any additional services at school, other clinics, and/or hospitals (speech therapy, reading assistance, non-general education classes, visual, hearing, psych evaluations, medical, etc.)? *

Yes
No

If yes, please list previous companies/providers:

Please list dates of previous services:

Current School:

Grade:

Describe performance in school (strengths and areas requiring assistance): *

Does the patient receive any services in the school (speech therapy, language development, reading, non-general education classroom, occupational therapy, physical therapy, etc.)? *

Yes
No

If yes, please describe

Are you concerned with the patient’s social skills? *

Yes
No

Is the patient aware of the speech/language/feeding difficulties they are having? *

Yes
No

Does the patient prefer to play alone? *

Yes
No

Does the patient have a close friend? *

Yes
No

Does the patient prefer to play with older or younger children? *

Older
Younger

Does the patient have difficulty concentrating? *

Yes
No

Describe how the patient interacts with their peers: *

What are the patient’s overall strengths? *

What are some areas the patient requires assistance with? *

What kinds of activities/toys does the patient enjoy? Specific interests? *

How does the patient play with toys when they are alone? *

What other things should we know about this patient to help them be successful? *

Tell us what matters the most to you/your family/the patient’s guardians. What are your goals for therapy/treatment for this patient? *

Are there any culturally significant holidays, customs, words, and/or images you would like the therapist to incorporate/exclude from therapy or understand? *

Yes
No

If yes, please describe: *

Description of Patient: *

Active
Affectionate
Aggressive
Calm
Cautios
Curious
Demanding
Difficult to Comfort
Distractible
Fearful
Fearless
Fussy
Insecure
Motivated
Passive
Persistent
Playful
Shy
Stubborn
Withdrawn
Stubborn
Withdrawn

Medical History

Does the patient have any medical diagnoses, disabilities, or suspected diagnoses? *

Yes
No

If yes, please list diagnoses, dates of diagnosis, and provider name:

Has the patient ever had surgery? *

Yes
No

If yes, please list:

Is the patient currently taking any medications? *

Yes
No

If yes, please list name of medication, how long the patient has been taking this, and dosage:

Is the patient allergic to any foods, medications, items, etc.? *

Yes
No

If yes, please list:

Has hearing been tested? *

Yes
No

If so, when?

Results?

Has the patient had any ear trouble (such as earaches, infection, evidence of hearing loss?) *

Yes
No

If yes, please describe:

If yes, when?

Has the patient ever had ear (PE) tubes inserted? *

Yes
No

If yes, when?

If yes, does the patient still have ear (PE) tubes? *

Yes
No

Has the patient ever worn eyeglasses or had any difficulty with eyes? *

Yes
No

If yes, please describe:

Has the patient ever had dental difficulties? *

Yes
No

If yes, please describe

Does the patient breathe with their mouth open? *

Yes
No

If yes, when

Has the patient had tonsils and/or adenoids removed? *

Yes
No

If so, when?

Has the patient seen a specialist (i.e. GI, orthodontics, audiology, ENT, etc.) for any reason? *

Yes
No

If yes, please list:

Are you concerned with the patient’s feeding (i.e. only eating certain textures/foods, coughing or choking while eating, poor weight gain, etc ? *

Yes
No

*NOTE*: please contact the clinic administrator for a separate feeding history form if you would like a feeding evaluation. The feeding history form must be completed prior to a feeding evaluation.

Communication History

What is your primary concern? (Please check what applies) *

Articulation - Difficulty saying sounds in words clearly or correctly; difficult to understand.
Language - Difficulty following directions, answering questions, and/or difficulty or limited use of words, sentences and/or grammar to communicate wants or tells stories.
Fluency - Stuttering, repeats sounds/words, and/or has speech that is halting and not fluid.
Voice - Hoarse/breathy voice and/or is too quiet or loud.
Feeding - Very picky eater, only eats a limited number of foods, only eats certain texture, coughs/chokes on food or liquids, and/or has poor weight gain/growth.
Other (please specify any other concerns):

(Other: please specify any other concerns)

Are there any languages other than English spoken in the home? *

Yes
No

If yes, which one(s)?

Bilingual Patients Only:

Language (English, Spanish, Arabic, etc.) | % of time patient hears the language | % of time patient speaks the language | Does the patient understand the language? (yes/no)

Language (English, Spanish, Arabic, etc.) | % of time patient hears the language | % of time patient speaks the language | Does the patient understand the language? (yes/no)

Is the patient’s speech understandable to: *

You? *

Yes
No

To strangers? *

Yes
No

To others living in the home? *

Yes
No

List sounds or words the patient has difficulty saying: *

Does the patient seem to follow directions? *

Yes
No

Does the child prefer to use speech or gestures when communicating? My child prefers to communicate via: *

Body Language
Augmentative Communication
Eye Gaze
Vocalization
Facial Expressions
Single Words
Manual Sign Language
Phrases
Pointing/Gesturing
Sentences
Picture Communication

Do you have any further questions? *

Yes
No

If yes, Please Comment Below *

Patient or Parent / Guardian Signature (Printed name will count as Signature) *

Relationship to Patient *

Date *

Contact Us

(972) 454-9309
Info@SynapticPediatricTherapies.com

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Ft Worth Area with multiple locations

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Copyright © 2022 Synaptic Pediatric Therapies, LLC. All rights reserved.

Digital Transformation by Digital Marksmen

Menu

Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Careers
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

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