Patient History Form Speech

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

Birth History

Developmental History

SOCIAL/EDUCATIONAL HISTORY

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

Medical History

*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

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)