Speech Language and Hearing History Form

As an infant, did your child babble and play with sounds?

When did your child speak his/her first word?

When did s/he begin to use 2-word phrases?

Does s/he prefer to use gestures? If so, give examples:

Examples of child’s speech

How well can your child be understood by parents: (Use %)

How well can your child be understood by siblings: (Use %)

How well can your child be understood by friends: (Use %)

How well can your child be understood by strangers: (Use %)

Has speech/language been tested? By whom and when?

If yes, where/when? What were they working on?

Have you seen any improvements or changes in your child’s speech/language over the past 6 months?

Has your child received any other evaluation or therapy? (e.g. physical therapy, counseling, occupational therapy, vision etc)?

Has vision been tested? By whom and when?

Has hearing been tested? By whom and when?