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New Patient Form Print this page
HELEN DUHON & ASSOCIATES, L.L.C. FRANKLIN SPEECH AND LEARNING CENTER 2117 Hillsboro Road Franklin, TN 37069 ________________________________________________________________________ Phone (615)591-3244 Fax (615) 591-3454 Email helduhon@bellsouth.net
PATIENT INFORMATION Date: _______________ Child’s Full Name: _______________________________ Name child prefers to be called: _________________________________________ Age: ________DOB: _____________Grade: ______ School: __________________ Parent’s Name(s): ____________________________________________________
Address:
____________________________________________________________ Phone Home: ______________________ Cell Mom: ________________________ Cell Dad: ________________ Wk Mom: _______________ Dad: _______________ Contact email address: ________________________________________________ Physician’s name: _____________________________________________________ Name of physician’s practice: ___________________________________________ Address: ___________________________________________ PH:______________ How did you find out about our office? ____________________________________ Please explain why you are requesting an evaluation/therapy: ____________________________________________________________________ ____________________________________________________________________ At what point did you become concerned? _________________________________ Has your child ever received a speech/language evaluation? __ yes __ no If so, when & where? __________________________________________________ Has your child ever received an occupational therapy eval.? __ yes __ no If so, when & where? __________________________________________________
Has
your child received therapy for an identified speech or
language or Please list any diagnosis that your child has received: _______________________ ____________________________________________________________________ ____________________________________________________________________
BIRTH HISTORY:
Please describe Mother’s health during pregnancy: ___excellent ___ good ___ poor
Please
briefly describe any problems/illness you experienced during
________________________________________________________________________ Was your child full-term? ___ yes ___ no List any complications during delivery:________________________________________ ________________________________________________________________________ What were the Apgar scores? (if known)_______________________________________
Describe your child’s health immediately after birth while
in the hospital: ________________________________________________________________________
Please list any serious illnesses, injuries or surgeries
since birth and the ________________________________________________________________________ ________________________________________________________________________ Has your child had a history of ear infections? ____yes ____no
Has your child had tonsils or adenoids removed? ________________________________ If so, at what age? ________________________________________________________
DEVELOPMENTAL GROWTH:
Please
list the approximate age at which your child reached the
following
How much cooing did your child do? ______ Great amount ______ Moderate _____ Little _____ None How much babbling did your child do? ______ Great amount ______ Moderate ______ Little _____ None How much did your child cry as an infant? ______Great amount ______ Moderate ______ Little _____ None Describe your child’s current vocabulary: ______ Appears normal _____ Appears delayed If delayed, then how many words is your child currently saying? ____ 1000’s ___ 100’s ___ 50 or less ___ 25 or less ___ 10 or less ___ none If your child is non-verbal, how is he/she communicating? ________________________________________________________________________
Does
your child use language for a variety of purposes? (i.e.
greet others,request objects, protest) ___ yes ____ no Does your child engage in social conversations? ___ yes ___ no
How
does your child’s speech/language development compare to
siblings? Is your child’s coordination good? Yes __ No __ If no, describe: ________________ ________________________________________________________________________
Does
your child interact well with other children? ___ yes
___ no How would you describe your child’s personality? (check all that apply)
___
Friendly ___ Shy ___ Talkative ___
Nervous ___ Easy-going __Quiet ___ Passive ___ Strong-willed _________________________________Other What type of reward system appeals to your child? ____________________________ _______________________________________________________________________
Is
there any history of speech/language problems or learning
disabilities Is there any history of sensory concerns in the family? __yes __no If yes to the above questions, please explain: ________________________________
_______________________________________________________________________ Is there more than one language spoken in the home? ___ yes ___ no If so, what languages? __________________ Which is primary? _____________
Name DOB AGE GRADE Any concerns?
_________________________________________________________________________
May we
have your permission to share test results, therapy
notes,evaluations, and
Please
list any other schools or agencies we may share this
information with: __________________________________________________________________
Signature ________________________________________________________________ Relationship to child _______________________________________________________ Person who completed this form _____________________________________________
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