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Speech Ouestionnaire

Please complete this questionnaire prior to your first appointment.

Speech Questionnaire

Your Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Name of Child*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Who lives with the child at home?*
Who is available to do 10 mins practice with child each day? (if recommended)*
Consents
Consent forms completed:*
- Privacy
- Photo and video
- Telehealth
If receiving NDIS, do you give consent for allied health to receive a copy of your plan?*
- Yes
- No
- I don't receive NDIS
Reason for Referral
Who referred your child?*
- GP
- Nurse
- Allied Health
- Educator
- Parent
- Other
Other*
Why was the child referred?*
What are your main concerns?*
Telehealth
Will your child be able to attend an initial 30 minutes telehealth session via zoom?*
- Yes
- No
A laptop, a tablet or phone with a reliable internet connection and a quiet room will be required.
Who will be available to facilitate this session between your child and therapist?*
- Parent
- Educator
- Other
Other*
Background
Were there any complications during pregnancy or birth?*
- Yes
- No
How many weeks was your child born at?*
weeks
Did you experience any feeding difficulties when your child was born?*
- Yes
- No
Was your child breast or bottle fed?*
- Breast fed
- Bottle fed
At what age did your child transition to solids? How was their transition to solids? Were there any difficulties?*
Are there any current difficulties with eating, drinking or swallowing?*
- No
- Yes, with eating
- Yes, with drinking
- Yes, with swallowing
Does your child have any oral habits?*
- Thumb/finger sucking
- Chewing clothes/hair
- Sucking blanket/toys
- Other
Other*
Has your child had any ear infections?*
- Yes
- No
When and for how long?*
Has your child experienced reflux?*
- Yes
- No
When and for how long? Please describe any treatment that was given.*
Does your child have any allergies?*
- Yes
- No
Does your child ever snore?*
- Yes
- No
Is your child currently taking any medication?*
- Yes
- No
Does your child have any medical diagnosis?*
- Yes
- No
Has your child had a hearing test?*
- Yes
- No
When?
Are you able to supply the results?*
- Yes
- No
Is your child currently under the care of any medical, educational or allied health professionals?*
- Pediatrician
- Ear, nose and throat specialist (ENT)
- Psychologist
- Occupational Therapist
- Speech Pathologist
- Physiotherapist
- Orthodontist
- Learning Support Teacher
- Other
- None of the above
Other*
Do you give permission for Leor allied health staff to collaborate with the above professionals and to exchange information relevant to your child's care and development?*
- Yes
- No
Pediatrician Contact Details
Phone*
Email*
Ear, nose and throat specialist (ENT) Contact Details
Phone*
Email*
Psychologist Contact Details
Phone*
Email*
Occupational Therapist Contact Details
Phone*
Email*
Speech Pathologist Contact Details
Phone*
Email*
Physiotherapist Contact Details
Phone*
Email*
Orthodontist Contact Details
Phone*
Email*
Learning Support Teacher Contact Details
Phone*
Email*
Please give contact details for the professional your child is under the care of
Phone*
Email*
Development
Did or does your child have any difficulties with the following?*
- Sitting up
- Crawling
- Pincer grip
- Drawing
At what age did your child begin walking?*
Language Milestones
At what age did your child begin to babble?*
At what age did your child say their first words (12 months)?*
At what age did your child begin to say 2 word phrases (2 years)?*
At what age did you child begin talking in full sentences?*
Expressive Language
Do you have any concerns with your child’s vocabulary? e.g. does your child overuse non-specific words such as “I want this.”*
Do you have concerns about your child’s ability to use appropriate sentence structure?*
Do you have concerns about your child’s ability to use grammar (e.g. appropriate use of past tense / plural etc)?*
Receptive Language
Is your child able to follow instructions (e.g. “Get your hat” or “sit at the table”)*
Do they understand wh- questions? (eg. who, what, where)*
Speech
Does your child have trouble making any of the speech sounds?*
- Yes
- No
What sounds have you noticed? Please give examples if possible.*
Did/Does anyone else in the family have difficulties with speech sounds?*
- Yes
- No
If so, can you please give examples?*
Fluency (Stuttering)
In everyday speech does your child often have:*
- Repetitions in their speech
- Pauses
- Overuse of filler words (e.g. “um”, “ahh” etc)
Does anyone else in the family have difficulties with stuttering?*
Education and social development
Did/ does your child currently attend play group outside the family home?*
- Yes
- No
Does your child attend any regular social outings (e.g play dates, extra curricular activities, sports, mothers group)?*
- Yes
- No
Who does your child socialise with on a regular basis?*
- Immediate family/siblings
- Grandparents
- Cousins
- Aunties
- Uncles
- Family friends
- Friends from play group
- Friends from mothers group
- Friends from preschool
- Friends from school
How many siblings and what are their ages?*
Play
How would you describe your childs play skills? (tick all/any that apply)
- Enjoys playing alone
- Enjoys playing alongside other children (e.g. will sit next to others and play with similar toys but is not interacting with play partner)
- Enjoys joint play and interacting with other children
- Enjoys play with parent/care
- Requires the parent/carer/play partner to initiate play
- Does your child participate in turn taking activities easily?
- Does your child engage in pretend and imaginative play?
Do you have any comments regarding your childs play skills?
Goals
What are your main goals for your child's communication?*

Phone: 02 9051 0511
Email: learn@leor.com.au

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