Client Background Information: Child Age 6 and Up - Pathways Pediatrics

Name of person completing form (relationship to client) *

Child's name *

Gender *

Date of Birth *

Age *

Primary Address *

Parent/Guardian Name(s) *

Primary Phone *

Alternate Phone *

Email *

Alternate Email Address *

Please list other children in family (including age) *

Referred by (e.g. parent/school/doctor)

Reason for completing this form *

Speech services
OT services
Other

If other, please describe

Does your child have any diagnoses or disorders? *

Yes
No

If yes, please describe *

Please indicate any major illnesses which the child has had, such as high fevers, measles, tonsillitis, many ear infections, etc. *

Does your child have any allergies? *

Yes
No

If yes, please describe

Has the child been seen by a speech-language pathologist *

Yes
No

If yes, when?

If yes, name of SLP and facility

If yes, findings

Has the child been seen by an occupational therapist *

Yes
No

If yes, when?

Name of OT and facility

If yes, findings

Has the child been seen by other professionals (e.g. psychologist, developmental pediatrician, etc.) *

Yes
No

If yes, please describe

Speech and Language History

What is your child's most frequently used language?

Any other languages?

Do you have any concerns with your child’s speech sound production? *

Yes
No

Please describe. (e.g. Child produces “snake” as “nake,” or has a frontal lisp, or incorrect R production)

Do you have any concerns with your child’s expressive language use? *

Yes
No

Please describe. (e.g. Leaves out some words and does not use full sentences, is not using verbs correctly, does not ask or answer questions appropriately)

Do you have concerns with your child’s receptive language use? *

Yes
No

Please describe. (e.g. Can they follow single step directions (point to your nose), two step or multistep directions (go to the car, get your backpack, and put it on the kitchen table))

How well do you understand your child (from 0% to 100%) *

How well do you other family members understand your child (from 0% to 100%) *

How well do you other strangers understand your child (from 0% to 100%)? *

What does your child do if they are not understood? *

Does your child stutter? (e.g. gets stuck, repeats sounds/words) *

Yes
No

If yes, describe

Hearing

Has your child had ear infections? *

Yes
No

If yes, how many and please describe

Does the child seem to have any difficulty hearing? *

Yes
No

If yes, describe

Has your child had a hearing test? *

Yes
No

If yes, what were the results and recommendations?

Vision

Has your child had their vision screened by an optometrist in the past year? *

Yes
No

Any concerns?

Social/Play History

Does your child enjoy or avoid the company of other children? *

What are your child’s favourite interests? *

Does your child make eye contact with you when speaking or interacting? *

Do you have concerns with your child’s social use of language? *

Feeding, Swallowing and Oral Structures

Is your child a picky eater? (Do they avoid certain textures, types of food, etc.?) If yes, describe *

When your child eats, do they frequently have food left on their face? *

Yes
No

When your child eats, do they make a lot of noise, or a lot of smacking sounds? *

Yes
No

Has your child ever been told they have a tongue tie? *

Yes
No

If yes, when?

Does your child have any oral habits (e.g. thumb or finger sucking, blanket sucking/chewing, lip or tongue sucking)? Or did they used to? *

Yes
No

If yes, please provide duration, frequency and if/when it stopped.

Has your child’s dentist or orthodontist mentioned any concerns? *

Yes
No

If yes, please describe.

Does your child drool or have excessive saliva? *

Self Help Skills

Do you have any concerns with your child’s ability to complete self help skills that you would expect for their age (e.g. putting on their clothing, tying shoes, managing utensils at mealtime, using the toilet independently)?

Prenatal and Birth History

Please describe if there were any any complications during pregnancy or birth

Education

Does your child currently attend school? *

Yes
No

If yes, list school and grade

Has your child’s teacher reported any concerns? *

Yes
No

If yes, please describe.

Is your child currently receiving any supports at school? *

Yes
No

If yes, please describe.

Additional Comments

Please use this space to comment on any other information you feel is important.