ࡱ> G bjbj iifIL L 8*7"EEE6 6 6 6 6 6 6$9<TD6qE#"EEED6g7}}}E6}E6}}jZ2J5Z242 6707d4<md<dJ5<J5EE}EEEEED6D6EEE7EEEE<EEEEEEEEEL X :  SEQ CHAPTER \h \r 1 THE UNIVERSITY OF WESTERN ONTARIO H.A. LEEPER SPEECH AND HEARING CLINIC Elborn College London, ON N6G 1H1 519-661-2021 Speech Clinic Intake form: Child C O N F I D E N T I A L Purpose Statement: The University of ҹվ Ontario is committed to protecting the privacy of personal information that is shared with us. To view our privacy policies and initiatives, refer to our Privacy Office web site at  HYPERLINK http://www.uwo.ca/privacywww.uwo.ca/privacy. The H.A. Leeper Speech and Hearing Clinic collects and uses your personal information in order to facilitate treatment, to contact you about appointments, and to process payments. DATE: ______________________________ PERSON COMPLETING FORM: _______________________________ RELATIONSHIP TO CLIENT: __________________________________ IDENTIFICATION: Childs NameDate of Birth Month / Day / YearPronouns  Home Address: Street City Prov. Postal Code Parent/Guardians Name: Cell/Home Phone Number:Address (If different from childs): Parent/Guardians Name:Cell/Home Phone Number:Address (If different from childs): Name of Family Doctor:Phone Number: Referred by:Phone Number:Other children in family:NameAgeGradeSpeech, Hearing, or Medical Difficulties Reason for Referral: Describe your childs speech, language, fluency or voice difficulties: _________________________________________________________________________________________________ __________________________________________________________________________________________________ When was this first noticed: ____________________________________________________________________ Please describe if there is a family history of speech, language, fluency, or voice difficulties. __________________________________________________________________________________________________ III. GENERAL DEVELOPMENT Prenatal and Birth History: Were there any complications with this pregnancy and delivery? 9 Yes 9 No If yes, please describe: _______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Motor Development: Did your child have difficulties developing their motor skills (e.g., sitting unsupported, learning to walk, climbing stairs, riding a bike, skipping, toilet training)? If yes, please describe: _______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child eat with a: Spoon? 9 Yes 9 No Fork? 9 Yes 9 No Knife? 9 Yes 9 No Does your child colour 9 Yes 9 No Does your child use scissors? 9 Yes 9 No Does your child dress and undress himself? 9 Yes 9 No Does your child have chewing or swallowing difficulties? 9 Yes 9 No If yes, please describe: _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child drool? 9 Yes 9 No C. HEALTH HISTORY: Please indicate any illnesses, operations, or hospitalizations that your child has experienced (e.g., high fevers, measles, tonsillitis, ear infections, concussions, tongue/lip/palate repair, etc) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have allergies? 9 Yes 9 No If yes, please describe: __________________________________________________________________ Does your child require medication for the allergy? Please explain: _____________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is your child currently taking any other medication: 9 Yes 9 No If yes, please describe: ________________________________________________________________ __________________________________________________________________________________________ Have there been any additional health problems, such as behaviour, attention, sleeping, or toileting difficulties: 9 Yes 9 No If yes, please describe: ________________________________________________________________ __________________________________________________________________________________________ SPEECH AND HEARING BACKGROUND Did your child babble during the first 6 to 12 months of age? 9 Yes 9 No Is your child talking? If no, skip to question 7. At what age did your child say first words? ________________________________________________ At what age did your child use more complete short sentences? _________________________________ Please give some examples of sentences your child used today: _________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does your child understand the following: short requests such as Get your shoes or Comb your hair? 9 Yes 9 No stories such as  The Three Bears ? 9 Yes 9 No Children s television programs? 9 Yes 9 No Dinnertime conversation? 9 Yes 9 No Adult conversation? 9 Yes 9 No Does your child have difficulty saying certain sounds? 9 Yes 9 No If yes, please describe: __________________________________________________________ _____________________________________________________________________________________ Whats the language you are most comfortable speaking? ____________________________________ Is this the language you speak at home? 9 Yes 9 No Do you require a translator during clinic visits? 9 Yes 9 No Does your child seem to have any difficulty hearing? 9 Yes 9 No If yes, please describe: __________________________________________________________ ____________________________________________________________________________________ EDUCATIONAL BACKGROUND 1. 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______________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list some of the childs favourite activities: ________________________________________________ __________________________________________________________________________________________ Are there any behaviour challenges? 9 Yes 9 No If yes, please describe (examples: hyperactivity, difficulty concentrating, underactive child, irritable): ___________________________________________________________________________________ ADDITIONAL INFORMATION Is there any other information which you feel will help us to understand your child better? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What are you hoping to get out of our service? 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