General: REGISTRATION & HISTORY Pt’s Full Name: Date of Birth: Home Phone # Address: Age: School: City/State/Zip Gender: Grade: Parent/Guardian #1 Parent Guardian #2 Phone # Phone # Other Children in family: Name Age Sex Grade ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Has anyone in the family ever been diagnosed with any of the following: ADHD, ADD Speech/Hearing disorders Autism Spectrum disorder Yes Yes Yes No No No Is there a language other than English spoken in the home? Yes No If yes, which one ? __________________________________________________________________ Does the child speak the language ? Yes No Does the child understand the language ? Yes No Who speaks the language ? __________________________________________________________ Which language does the child prefer to speak at home ?______________________________ Describe your concerns regarding your child’s social skills? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Has your child ever had speech therapy ? Yes No If yes, where and when ? ________________________________________________________ What was he/she working on ? ___________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.) ? Yes No If yes please describe. _________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Is your child aware of, or frustrated by, any speech/language difficulties ? _________________________ ___________________________________________________________________________________ What do you see as your child’s most difficult problem in the home ? ____________________________ ___________________________________________________________________________________ What do you see as your child’s most difficult problem in school ? _______________________________ BIRTH HISTORY Was there anything unusual about the pregnancy or birth ? Yes No If yes, please describe. ________________________________________________________ ___________________________________________________________________________________ How many months was the pregnancy ? ____________________________ Did the child go home with his/her mother from hospital ? Yes No If child stayed at hospital, please describe why and how long.___________________________ ___________________________________________________________________________________ Has your child had any of the following ? Adenoidectomy Encephalitis Seizures Allergies Flu Sinusitis Breathing difficulties Head Injury Sleeping difficulties Chicken pox High fevers thumb/finger sucking habit Colds Measles Tonsillectomy Ear infections How many ? _________ Mumps Vision problems Ear tubes Scarlet fever Other serious injury/surgery: _____________________________________________________Is your child currently (or recently) under a physician’s care ? Yes No If yes, why ?________________________________________________________________ Please list any medications your child takes regularly:________________________________________ ___________________________________________________________________________________ DEVELOPMENT HISTORY Please tell the approximate age your child achieved the following developmental milestones: _________________ Babbled ________________ Sat alone _________________ First word ________________ Walked _________________ Put two words together ________________ toilet trained _________________ Sentences ________________ spoke in short _________________ ________________ _________________ ________________ Does your child: choke on food or liquids brush his/her teeth and or allow brushing ? currently put toys/objects in his/her mouth ? drool CURRENT HISTORY DOES YOUR CHILD: Know his/her name ? respond to his/her name ? repeat sounds, words or phrases over and over ? understand what you are saying ? retrieve/point to common objects upon request (ball, cup, shoe) ? follow simple directions (“shut the doors” or Get your shoes”) ? respond correctly to yes/no questions ? respond correctly to who/ what/ when/ where/ why/ questions ? Your child currently communicates using: body language sounds words 2 - 4 word sentences 4 or more word sentences others _______________________________________________________________ Behavioral characteristics: Cooperative restless attentive poor eye contact willing to try new things not able to concentrate on one activity Frustrates easily plays alone destructive/aggressive separation difficulties bad behavior SCHOOL HISTORY (IF APPLICABLE) Grade;________ Name of School:____________________ Teacher:____________________________ Has your child been held back ? Yes No Is your child receiving tutoring in any subject ? Yes No If yes, describe:________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ADDITIONAL COMMENTS _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Phone: Primary Care Physician: Pt’s Guardian Email: Pt’s Full Name: Pt’s Soc. Sec. Number: Address: City/State Zip: Gender: Date Of Birth: Parent/ Guardian #1 Age: Parent/ Guardian #2 Soc. Sec. Number: Date Of Birth: Soc. Sec. Number: Date Of Birth: Home Phone: Cell Phone: Home Phone: Cell Phone: Emergency Contact: Phone #: Primary Ins. Co: Phone #: Address: City/ State Zip: Insured: Relationship: Policy/ Soc. Sec. # Group: Secondary Ins. Co. Phone #: Address: City/ State Zip: Insured: Relationship: Policy/ Soc. Sec. #: Group: Check this box if you do not wish to have your medical information discussed with anyone. Please list any/all people that you are permitting Rescue My Speech to discuss and/or view your medical treatment with and their relationship to you. If no name is listed, information will only be discussed with patient. The Information stated above, to the best of my knowledge, is correct and complete. I authorize Rescue My Speech and/or their billing service to bill my insurance of any/all services rendered on the person listed above. I also allow my insurance company to send payments directly to Rescue My Speech. I understand that I am responsible for any co-payments and/or deductibles not covered by my insurance. If for any reason a collection agency is required to collect outstanding funds, I understand that I am responsible for collection fees as well. I authorize Rescue My Speech to release all necessary information to my insurance company. The below signature releases any/all medical records past or present to Rescue My Speech from other providers. Signature: Relationship: Date: