Case History FormPrivate Patients FAMILY INFORMATION Child’s Name * First Name Last Name Gender * Please select Male Female Date of Birth * MM DD YYYY Your Email Address * Your Address * Does the child live at home with both parents? * Please select Yes No Mother’s Name First Name Last Name Mother’s Occupation Mother’s Contact Number Father’s Name First Name Last Name Father’s Occupation Father’s Contact Number Siblings Please list any siblings, with gender and DOB for each. Is there a language other than English spoken in the home? Please select Yes No If yes, what language? OTHER PROFESSIONALS WORKING WITH YOUR CHILD Please list names, with profession and contact number. SPEECH AND LANGUAGE INFORMATION I have concerns about my child’s: Speech development (pronunciation of sounds) Fluency/Stuttering (repeating sounds, words, phrases, getting stuck on words) Vocal quality (unusual voice quality, too high/low, hoarse) Expressive language development (e.g. amount of words, use of grammar, formulating sentences, retelling events) Receptive language (e.g. following instructions, understanding questions) Literacy (reading/writing) Other Please describe your concerns in more detail: When was the problem first noticed, and by whom? Approximate age when your child said single words: Approximate age when your child said two-word phrases: Approximate age when your child used simple sentences: Please indicate any family history of the following: Speech/language problems Hearing problems Learning problems Psychological problems Literacy problems If you indicated family history above, please clarify who and when: Previous Speech Pathologist (if applicable): BACKGROUND INFORMATION Were there any concerns during pregnancy/birth? If yes, please explain. Has your child experienced any of the following? Medical treatment Significant injuries Illness If yes to any of the above, please explain. Has your child experienced any ear infections? If yes, please explain. Has your child’s hearing been tested recently? If yes, when was the test and what were the results? Do you have concerns about your child’s physical development? Please select Yes No Please list any current diagnoses: MOTOR MILESTONES Approximately when did your child reach the following milestones - sitting? walking? crawling? Please indicate which of the below your child can do independently: Toilet Feed Dress SOCIAL/BEHAVIOURAL HISTORY Please tick the points that are true for your child: My child plays well with other children My child engages well with adults My child has difficulties attending/concentrating My child is unusually active I have trouble disciplining my child EDUCATION HISTORY Does your child attend any of the below? Daycare Kindergarten Pre-Primary School If yes to the above, please confirm details and any concerns of daycare/school: AUTHORITY TO SIGN Name of person completing this form * First Name Last Name Relationship to Child * Cancellation Policy * I have read and accept the Little Lions cancellation policy. Thank you! Your submission has been received. Please click here to read our Cancellation Policy before booking
