Child Assessment
Child – 1-12 years old
Patient’s Name
Birthday
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Month
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Day
Year
Age
Please use this form if Age is above 1 and less than 13
Today’s Date
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Month
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Day
Year
Medical issues
Medications
Allergies
Previous clip or release of tongue?
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Month
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Day
Year
Have you experienced any of the following issues? Please check or elaborate as needed.
Speech
Frustration with communication
Difficult to understand by parents
Difficult to understand by outsiders
% of time you understand your child
Difficulty speaking fast
Difficulty getting words out
Trouble with sounds
Speech delay
Stuttering
Speech harder to understand in long sentences
Speech therapy
Mumbling or speaking softly
Baby Talk
Trouble with sounds (which?)
Speech delay (when?)
Speech therapy (how long)
Feeding
Frustration when eating
Difficulty transitioning to solid foods
Slow eater (slow to finish meals)
Grazes on food throughout the day
Packing food in cheeks like a chipmunk
Picky with textures
Choking or gagging on food
Spits out food
Other
Picky with textures (which?)
Other please explain
Nursing or Bottle-Feeding Issues as a Baby
Painful nursing or shallow latch
Poor weight gain
Reflux or spitting up
Unable to hold pacifier
Milk dribbling out of mouth
Poor Supply
Nipple shield required for nursing
Clicking or smacking noise when eating
Other
Other please explain
Sleep issues
Sleeps in strange positions
Kicks and flails around at night
Wakes easily or often
Wets the bed
Wakes up tired and not refreshed
Grinds teeth while sleeping
Sleeps with mouth open
Snores while sleeping
Gasps for air or stops breathing (sleep apnea)
Snores while sleeping (how often)
Other related issues
Neck or shoulder pain or tension
TMJ Pain, clicking, or popping
Headaches or migraines
Strong gag reflex
Mouth open /mouth breathing during the day
Tonsils or adenoids removed previously
Ear tubes previously
Reflux
Hyperactivity / Inattention
Constipation
Reflux
Medicated
Not medicated
Physician
Speech Therapist
Who referred you to us?
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