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* MM slash DD slash YYYY Age* Sex* Male Female Please indicate your primary concern about your child’s speech, language, feeding, or swallowing skills:*Child’s Primary Care Physician:* Any medical diagnosis?*If "Yes" please list below. Yes No Please 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. Yes No Please 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? Yes No What were the results and where did the testing take place?*Has your child had any Speech/Language or Feeding Therapy?*If “yes” please list where did the therapy takes place below? Yes No 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 Search Physician referral CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
