TheraKids Plus, Inc. Speech and Language History Speech and Language Questionnaire - English Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Telephone Contact(Required) LANGUAGE Primary language spoken in the home: School: Vocabulary: How many words does your child consistently use? Understand: Please give examples: Sentences: Does your child combine words to form sentences? Yes No If “YES”, how many? Please give examples: Please answer “yes” or “no” or “sometimes” to the following questions:1. Does your child respond to his/her name? Yes No Sometimes 2. Will your child get common objects when asked? Yes No Sometimes 3. Does your child follow simple directions? Yes No Sometimes 4. Will your child point to pictures as you name them? Yes No Sometimes 5. Does your child label pictures? Yes No Sometimes 6. Does your child ask questions? Please give examples7. Does your child repeat or others’ expressions? Yes No Sometimes 8. Does your child repeat questions or parts of questions rather than answering them? Yes No Sometimes 9. Does your child consistently recite/repeat words from video tapes/DVDs, songs, or TV programs? Yes No Sometimes 10. Has your child said a word and few times, then never used it again? Yes No Sometimes If Yes When What words? 11. Did language development seem to just stop? Yes No Sometimes If Yes When 12. Does your child have trouble starting a conversation? Yes No Sometimes 13. Does your child have trouble interacting with peers? Yes No Sometimes How does your child indicate needs and or wants to you? How does your child indicate he/she does not want something or does not want to do something? SPEECH / ARTICULATION Does your child produce a variety of sounds? Yes No If “Yes”, please give examples: Do you have a difficult time understanding what your child is saying? Yes No Sometimes Please describe: Has your child ever been diagnosed as being “Tongue Tied”? Yes No When Did he/she have corrective surgery? Yes No When HEARING / FLUENCY / VOICEDoes your child have a diagnosed hearing loss? Yes No Does your child wear hearing aides? Yes No Does your child have a cochlear implant? Yes No Does your child have PE Tubes? Yes No Does your child have voice issues? Yes No Is your child hoarse? Yes No Does your child stutter? Yes No Is your child speech halting? Yes No
