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CAIRNS SPEECH PATHOLOGY CLINIC
5 Seaview Close Bayview Hts Cairns Qld 4868
ph (07)40331230 0412 836947
The information you provide will help the therapist gain a thorough understanding of your child and the
difficulties s/he is experiencing, enabling provision of the most appropriate speech pathology service
and management in the future.
BIOGRAPHICAL INFORMATION:
Child’s Name: ____________________________________________________________________
Date of Birth: ____________________________________ Present Age: ___________________
Residential Address: ___________________________________________ Postcode: __________
Mother’s Name: ________________________ Occupation: _______________________________
Father’s Name: _________________________ Occupation: _______________________________
Phone No. (Home): _____________ (Mobile): ______________ (Work): ____________________
Languages spoken at home: _________________________________________________________
Siblings:
Name Date of Birth Age
________________________________ _________________ __________
________________________________ _________________ __________
________________________________ _________________ __________
________________________________ _________________ __________
OTHER SERVICES INVOLVED:
If your child has ever visited the following services, please give details.
Service: Consultant’s name and contact number:
Doctor (GP): ________________________________________________
Paediatrician: ________________________________________________
Ear Nose & Throat Specialist: ________________________________________________
Audiologist: ________________________________________________
Dentist: ________________________________________________
Eye Specialist: ________________________________________________
Speech Pathologist: ________________________________________________
Physiotherapist: ________________________________________________
Occupational Therapist: ________________________________________________
Other: ________________________________________________
BIRTH HISTORY:
Pregnancy was (please tick appropriate response):
□ Full term □ Premature □ Overdue
During pregnancy, mother was (please tick appropriate response & provide details if necessary):
□ Healthy □ Unwell
_____________________________________________________________________________________
___________________________________________________________________________
Delivery of baby was (please tick those applicable):
□ Normal □ Induced □ Breached □ Caesarean Section □ Forceps □ Vacuum □Difficult
Please provide other relevant information (e.g., complications before or during birth; jaundice;
breathing difficulties; convulsions; RH incompatibility; low birth weight; required tube feeding, oxygen,
ventilation etc.): ___________________________________________________________
________________________________________________________________________________
Baby’s birth weight was: ___________________________________________________________
General health of baby in first year: ___________________________________________________
DEVELOPMENTAL HISTORY:
Has your child ever had any of the following? If yes, please give details (including child’s age):
□ Asthma: ______________________________________________________________________
□ Frequent colds/flu: _____________________________________________________________
□ Ear infections (please state how often): _____________________________________________
□ Tonsillitis: ____________________________________________________________________
□ Mouth breathing: ______________________________________________________________
□ Thumb sucking: _______________________________________________________________
Is your child currently taking any medications? Please give details:
_____________________________________________________________________________________
___________________________________________________________________________
Has your child ever needed to be on any medications for a long period? Please give details:
_____________________________________________________________________________________
___________________________________________________________________________
FEEDING DEVELOPMENT:
During infancy how was your child fed? (Please tick appropriate response):
□ Breast fed □ Bottle fed □ Breast + Bottle fed □ Other □ Don’t
know
At what age were solids introduced to your child? _______________________________________
Has your child had any difficulties with any of the following (if yes, please give details):
Sucking: ________________________________________________________________________
Introduction of solids: ______________________________________________________________
Chewing: ________________________________________________________________________
Other: __________________________________________________________________________
Please tick items below that best describe your child’s current level of ability:
(a) Feeding:
□ Uses knife and fork □ Uses spoon
□ Uses fingers only □ General difficulty with feeding
□ Has to be fed □ Can usually manage alone but likes to be fed
□ Drinks from a cup with help □ Drinks from a cup on own
□ Very messy during meals □ Manages all meals well
□ Poor appetite □ Good appetite
DEVELOPMENTAL MILESTONES:
At what age did your child first:
Sit unsupported: _____________ Crawl: _____________ Walk alone: __________
Please tick items below that best describe your child’s current level of ability:
(a) Toileting:
□ Fully trained □ Indicates need, but requires help
□ Dry and clean if regularly toileted □ Poor day control
□ Poor night control □ Not toilet-trained at all
(b) Hearing:
Has your child’s hearing been tested? □ Yes □ No □ Don’t know
If yes, when was your child’s hearing tested? ___________________________________
Where or by whom was his/her hearing last tested? _______________________________
What were the results?
□ Normal hearing □ Hearing impairment
□ Grommets inserted □ Hearing aids required
If you have a report from the hearing assessment (regardless of the results), please attach a copy of it
to this form, or bring the original report with you to your first appointment.
(c) Vision:
Has your child ever had any problems with vision? □ Yes □ No □ Don’t know
If yes, please describe the problems and when they started: ________________________________
________________________________________________________________________________
(d) General Behaviours:
Please tick the appropriate boxes below if any of the following apply to your child:
□ Seems clumsy □ Loses balance easily
□ Walks in an awkward manner □ Repeatedly mimics what you say
□ Frequently throws tantrums □ Withdraws from social interaction (i.e. shy)
□ Aggressive and/or destructive □ Displays some repetitive behaviours
□ Likes to follow a strict routine □ Avoids making eye contact
□ Resistant to contact (i.e., not cuddly) □ Over-sensitive to sounds and/or surroundings
□ Easy to manage □ Strongly dislikes being separated from parent/carer
SOCIAL HISTORY:
Who is currently living at home? _____________________________________________________
________________________________________________________________________________
How does your child like to spend playtime? ___________________________________________
________________________________________________________________________________
Does your child have any preferred games, toys or hobbies? _______________________________
________________________________________________________________________________
Does your child usually play with (please tick):
□ No-one □ Older children □ Younger children □ Children his/her age
Is your child usually (please tick):
□ the leader in games □ the follower in games
Please tick the appropriate boxes as they apply to your child:
□ Friendly □ Nervous □ Confident
□ Shy □ Easy-going □ Anxious
□ Talkative □ Quiet □ Other: ________________________
EDUCATIONAL HISTORY:
Which, if any, of the following is your child involved in (please tick and provide details):
Organisation: Name of organisation & contact details:
□ Child-care/Day-care _____________________________________________________
□ Early Intervention Group _________________________________________________
□ Kindergarten ___________________________________________________________
□ Preschool ______________________________________________________________
□ Transitional Grade _______________________________________________________
□ Primary School __________________________________________________________
Does your child enjoy going? □ Yes □ No □ Don’t know
Has your child ever repeated a level of education (e.g., kindy, preschool, year one) or experienced any
difficulties (e.g., interacting with peers/teachers, behaviour, class work)?
□ Yes □ No □ Don’t know
If yes, please provide details: ________________________________________________________
________________________________________________________________________________
SPEECH & LANGUAGE HISTORY:
Do you have concerns about your child’s development/progress in any of the following areas? (Please
tick relevant boxes.)
□ Speech (saying sounds) □ Reading
□ Language (using & understanding words & sentences) □ Spelling
□ Voice quality □ Physical Skills
□ Fluency (stuttering) □ Feeding/Swallowing
Please describe, in your own words, your concerns regarding your child’s speech and/or language
development:__________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________
Who first noticed your child’s speech and/or language difficulties?__________________________
When were your child’s speech and/or language problems first noticed? (i.e., how long ago, and what
age was your child?): __________________________________________________________
________________________________________________________________________________
Have you tried to help your child in their area of difficulty at home?
□ Yes □ No
If yes, please describe ______________________________________________________________
________________________________________________________________________________
Do you think your child is aware of their difficulties/problems?
□ Yes □ No □ Don’t know
Has your child ever been teased about his/her speech and/or language difficulties?
□ Yes □ No □ Don’t know
If yes, please provide details: ________________________________________________________
_____________________________________________________________________________________
___________________________________________________________________________
How do family members/friends react to your child’s speech and/or language difficulties?
________________________________________________________________________________________________________________________________________________________________
Did your child babble and coo as an infant?
□ Yes □ No □ Don’t know
At what age did you child say his/her first word (other than “mama”)?________________________
At what age did your child begin to put two words together?________________________________
How many words long are your child’s sentences now?___________________________________
How does this development compare with other children in your family? (Please tick)
□ Earlier □ Same time □ Later □ Not applicable
How does your child currently communicate (e.g., uses talking; grunts; points; gestures; uses a sibling to
talk for him/her)? _________________________________________________________
________________________________________________________________________________
Can people other than immediate family members and close family friends understand your child’s
speech (please tick)?
□ Never □ Only if the topic is known □ Most of the time □ Always
Does your child have any relatives with a history of speech and/or language problems? (Including
aunties, uncles, grandparents, cousins, siblings, parents, etc.)
□ Yes □ No □ Don’t know
Please describe: __________________________________________________________________
________________________________________________________________________________
Is there any other information you would like to add that might assist me in working with your child?
__________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________
CONSENT TO RECEIVE SERVICES & CONSENT TO THE RELEASE OF INFORMATION:
I, ________________________________ (name of parent/guardian), hereby give permission for
_______________________ (child’s name) to receive Speech Pathology services from the Cairns Speech
Pathology Clinic.
Furthermore, I give permission for the Cairns Speech Pathology Clinic to provide information to, and
receive information from, other relevant professionals.
Name of person who completed this form:______________________________________
Relationship to child:_______________________________________________________
Signature: _____________________________________ Date:____________________
Thank you for taking the time to complete this form.
We will call you as soon as an assessment appointment becomes available.
I look forward to meeting with you and your child at your assessment appointment.
SPEECH PATHOLOGIST
Cairns Speech Pathology Clinic
