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Speech Ouestionnaire

Speech Questionnaire

Step 1 of 4

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Please complete this questionnaire prior to your first appointment.
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*
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*

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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
Name
First Last
Practice
Phone
Email
Ear, nose and throat specialist (ENT) Contact Details
Name
First Last
Practice
Phone
Email
Psychologist Contact Details
Name
First Last
Practice
Phone
Email
Occupational Therapist Contact Details
Name
First Last
Practice
Phone
Email
Speech Pathologist Contact Details
Name
First Last
Practice
Phone
Email
Physiotherapist Contact Details
Name
First Last
Practice
Phone
Email
Orthodontist Contact Details
Name
First Last
Practice
Phone
Email
Learning Support Teacher Contact Details
Name
First Last
Practice
Phone
Email
Please give contact details for the professional your child is under the care of
Name
First Last
Practice
Phone
Email
Development
Did or does your child have any difficulties with the following?
- Sitting up
- Crawling
- Pincer grip
- Drawing
- None of the above
At what age did your child begin walking?*

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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?*

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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
- Participates in turn taking activities easily
- Engages 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?*
If you would like to upload any reports, recordings or other documents relevant to the assessment, please attach them here.
Max. file size: 128 MB.

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

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