General Information Describe the child`s Speech
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General Information Child’s Name / Nombre del niño ___________________________________________________ DOB: ___/____/____ Age/Edad: _______ Parents’Name / Nombre de los Padres ______________________________________________________________________________________ Address / Domicilio ________________________________________City_________________________State______________ZIP__________ Home telephone/Telefono de la casa _______________________ ___ Cell phone/Telefono cellular_______________________________ Place of Birth/Lugar de nacimiento ______________________________ Length of Residence in USA/Tiempo de Residencia en USA ____ Physician’s Name/Nombre del Doctor ________________________________________________ Phone/Telefono _______________________ Does the child live with both parents?/Vive el niño con ambos padres? ________________________________________________________ Names and ages of Brothers and Sisters/Nombres y edades de los hermanos y hermanas __________________________________________ ________________________________________________________________________________________________________________________ Languages spoken at home/Idiomas hablados en la casa _____________________________________________________________________ Language spoken by the child/Idioma hablado por el niño __________________________________________________________________ Describe the child’s Speech-Language problem/Describa el problema de comunicacion del niño ____________________________________________________________________________________________________________ When was the problem a first noticed?/Cuando se noto el problema? ____________________________________________________________________________________________________________ Has the problem changed since it was first noticed?/Ha cambiado el problema desde que fue notado? ____________________________________________________________________________________________________________ Has any other specialist seen the client? If yes, indicate the type of specialist and when the child was seen/Ha sido visto el niño por otro doctor? En caso afirmativo indique la especialidad y cuando el niño fue visto. ____________________________________________________________________________________________________________ Prenatal and Birth History Was your delivery premature, normal, delayed, or cesarean?/ Fue su parto premature, normal, retrasado o cesarean? ____________________________________________________________________________________________________________ Did you smoke or consume alcoholic beverage regularly during the pregnancy?/ Fumo o o bebio alcohol durante el embarazo? ____________________________________________________________________________________________________________ Did you have any infections, illness, accidents, or injuries during the pregnancy?/ Tuvo infecciones, enfermedades, accidents o golpes durante el embarazo? ____________________________________________________________________________________________________________ When did you begin to receive medical attention for the pregnancy?/ Cuando empezo a recibir atencion medica con este embarazo? ____________________________________________________________________________________________________________ What medications did you take during your pregnancy? Que medicamentos tomo durante el embarazo? ____________________________________________________________________________________________________________ Where there any complications during the delivery? Tuvo complicaciones durante el parto? ________________________________________________________________________________________________________________________ Did you receive medications during the delivery? Recibio medicamentos dutante el parto? _______________________________________________________________________________________________________________________ What did the child weigh at birth? Cuanto peso el niño al nacer? ________________________________________________________________________________________________________________________ Did the child suffer any complications at birth? Sufrio el niño alguna complicacion al nacer? _______________________________________________________________________________________________________________________ Developmental History How old was your child when / Que edad tenia el niño cuando: • Sat without help/se sento sin ayuda _______________ • began to crawl/ empezo a gatear _________________ • walked without help / camino sin ayuda ___________ • said first words / dijo sus primeras palabras _________ • in what language / en que idioma ________________ • began to combine two words / empezo a combinar dos palabras ___________________ • began to combine three or more words / empezo a combinar tres o mas palabras _______________ Has or has had the child any feeding problems? / El niño ha tenido o tiene problemas para comer? _________ If yes, please describe / Si, por favor describalos _________________________________________________________________________________________________ How is the response of the child to sound? / Como es la respuesta del niño a los sonidos? _________________________________________________________________________________________________ Medical History Has the child had any of the following illnesses? / Ha tenido el niño alguna de las siguientes enfermedades? ______ Asthma / asma ______ bronchitis / bronquitis ______ convulsions / convulsiones ______ dehydratation / deshidratacion ______ epilepsy / epilepsia ______ high fever / fiebre alta ______ tonsil infection / infeccion de anginas ______throat infection / infeccion de la garganta ______ear infection / infeccion del oido How many? / Cuantas? ______ ______mumps / paperas ______bladder problems / problemas de la vejiga ______kidney problems / problemas de los riñones ______pneumonia / neumonia Any other illness? / Alguna otra enfermedad? _____________________________________________________________ Educational History Does the child attend day care or preschool? /Asiste el niño al colegio o guarderia? _________________________________________________________________________________________________ _________________________________________________________________________________________________ ____________________________ Signature / Firma _____________________________ Relationship to child / Parentesco ________________ Date
