Parent/Guardian Name Phone Number Preferred method of contactCallText Your email Patients Name Patients Date of Birth Primary Care Physician's Name: Other Specialist(s) YesNo If yes to Other Specialist(s) Current speech, language, and/or feeding concerns? Language(s) spoken at home? EnglishSpanishOther If Other Language(s) spoken at daycare/school? EnglishSpanishOther If Other What language(s) does the patient understand: EnglishSpanishOther If Other What language(s) does the patient speak? EnglishSpanishOther If Other Is the patient taking any medications? YesNo If yes to taking medications. Allergies? YesNo If yes to allergies. Most recent hearing screening Does the patient wear glasses? YesNo Previous Therapy? Did you notice improvement? YesNo Approximate date if discharged. Any pregnancy complications? Premature or Full-term? PrematureFull-Term Complications with labor/delivery? How Many week gestations Did the patient have to remain hospitalized? YesNo How Long? Did the patient require oxygen? YesNo Medical diagnoses/conditions. Hospitalizations/surgeries Developmental History Age patient crawled? walked? Babbled? Said first word? Combines words? Educational History Daycare or School? SchoolDaycareNot Applicable Name of daycare: Leave blank if not applicable. Name of school: Leave blank if not applicable. What grade?? Schedule? Does patient receive special services at school YesNo Social History/Family Who does patient reside with? Both ParentsOne ParentFamily MemberFoster ParentAdoptive Parent Addition Information