Child Case History Name of person completing this form.* First Last Relationship to Child*Phone*Email Address* Child’s Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Age*Sex*MaleFemalePlease indicate your primary concern about your child’s speech and language skills:*Child’s Primary Care Physician:*Any medical diagnosis?*If "Yes" please list below.YesNoPlease list medical diagnosis below*Has your child had an audiological evaluation (hearing test)?*If you respond "Yes" please list when and where it took place and the results.YesNoPlease list when and where it took place and the results.*Has your child had any Speech and Language testing?*If “yes” please list the results and where did the testing take place below?YesNoWhat were the results and where did the testing take place?*Has your child had any Speech and Language Therapy?*If “yes” please list where did the therapy takes place below?YesNoPlease list where did the therapy take place?*List any medications prescribed for your child.List any medications prescribed.Please explain if your child has had other significant medical treatment.Please feel free to indicate any questions or concerns that you would like to specifically discuss at your initial appointment.Please indicate how you heard about our services?Internet SearchPhysician referralCAPTCHANameThis field is for validation purposes and should be left unchanged.
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