To prepare for your child’s assessment, please fill out the background information below. If not applicable please leave blank.

Name of Mother
Name of Mother
Name of Father
Name of Father
Address
Address
Child's Date of Birth
Child's Date of Birth
If yes, does the child understand the language?
Does the child speak the language?
BIRTH HISTORY
MEDICAL HISTORY
Has your child had any of the following?
DEVELOPMENTAL HISTORY
Please tell the approximate age your child achieved the following developmental milestones...
Did your child have difficulty sucking?
Did your child dribble excessively?
Does your child prefer a soft food diet?
Does your child have difficulty chewing?
Does your child choke on foods or liquids?
Does your child currently put toys/objects in his/her mouth?
Does your child brush (or allow brushing of) his/her teeth?
PRESCHOOL HISTORY
Please leave blank if not applicable
SCHOOL HISTORY (if in school)
Please leave blank if not applicable
CURRENT SPEECH LANGUAGE
Does your child:
Please check relevant boxes
Does your child currently communicate using:
Please check relevant boxes
Behavioural Characteristics
Please check relevant boxes
SPEECH LANGUAGE THERAPY
Has your child seen a paediatrician?
Is the child aware of or frustrated by the speech or language difficulties?