1752 E Bullard Ave, Suite 101 Fresno, CA 93710 | 4144 S. Demaree St, Suite B, Visalia, CA 93277
(559) 970-8277
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Speech Therapy
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We currently offer individualized therapy sessions for clients focusing the following areas of communication:
Articulation
Language
Auditory Processing
Fluency (Stuttering)
Pragmatic (Social) Language
Early Intervention
Behavioral Services
Oral Placement
Pediatric Feeding
Literacy
Speech Therapy
Individualized Services
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Ortho Child Case History
Step 1 of 11
9%
Section 1
General Information
Today's Date
Date Format: MM slash DD slash YYYY
Child's Name
*
First
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Age
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Allergies
Emergency Contact Information
Name
*
First
Phone Number
*
Relationship to Client
Does the child live with both parents?
Select
Both Parents
Mother
Father
Guardian
If divorced, who has custody?
Select
Joint
Mother
Father
Other
Who does child spend most of his/her time with?
Parent/Caregiver #1 Name
Occupation
Home Phone
Cell Phone
Email
Parent/Caregiver #2 Name
Occupation
Home Phone
Cell Phone
Email
Siblings / Age
Other people in the home / Relation
Section 2
Physician Information
Child's Physician
Phone Number
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Section 3
Child's Behavior
What language(s) does the child speak?
Has your child received any speech therapy, occupational therapy, or physical therapy services? If yes, please describe what was addressed.
Section 4
Is the child adopted?
Select
Yes
No
Unknown
At what age did the child join the family?
Alcohol, drugs, smoking, or any medications during this pregnancy?
Select
Yes
No
Unknown
Please list alcohol, drugs, smoking, or any medications during this pregnancy.
Normal pregnancy and delivery?
Select
Yes
No
Unknown
Did your child have jaundice?
Select
Yes
No
Unknown
Weight at birth
Was oxygen or respiratory assistance required after birth?
Select
Yes
No
Unknown
Vaginal delivery?
Select
Yes
No
Unknown
Was your child breast fed?
Select
Yes
No
Unknown
Cesarean delivery?
Select
Yes, it was planned
Yes, it was a repeat C-section
Yes, it was an emergency
No
Unknown
Any difficulties with feeding?
Select
Yes
No
Unknown
Full-term pregnancy?
Select
Yes
No
Unknown
Did your child have normal feeding, weight gain, sleeping cycles, and temperament?
Select
Yes
No
Unknown
Section 5
Prenatal and Birth History
Describe mother’s general health during pregnancy (illness, accidents, prescription and non-prescription medications, etc.)
Length of pregnancy
Section 6
Medical History
Child’s general health is:
Select
Good
Fair
Poor
Is your child on any medications? If so, please list.
Describe any major illnesses, accidents, surgeries, or hospitalizations the child has had.
Has your child had ear infections?
Select
Yes
No
Unknown
How many ear infections?
Does your child have tubes?
Select
Yes
No
Unknown
Section 7
Developmental History
Please complete this section to the best of your ability. Write the approximate age when the child began to do the following.
Crawl
Sit
Stand
Walk
Feed Self
Dress Self
Use toilet
Coo
Babble
Use single words
Combine words
Name simple objects
Use simple questions
Engage in a conversation
Does your child have any motor difficulty, such as walking or running?
Describe any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing, etc.) your child has had.
Section 8
Educational History
School or Preschool
Grade
Teacher(s)
Describe any special services your child receives.
If enrolled for special education services, list main goals of the Individualized Educational Plan (IEP) or Individual Family Service Plan (IFSP).
Section 9
Orthodontic History
What phases has your child completed so far? Please include ages as well as the work completed:
What are future orthodontic plans?
What are the orthodontist's concerns?
How did you hear about The TALK Team?
Select
Family Member
Friend
Teacher
Doctor
Internet
Phone Book
Workshop
Insurance Network
Other
Section 10
The information provided in this document regarding my child is accurate and consistent to the best of my knowledge.
Electronic Signature
*
Date
Date Format: MM slash DD slash YYYY
Relationship to the patient
Section 11
I give The Talk Team permission to speak with the orthodontist regarding treatment and concerns.
Electronic Signature
*
Date
Date Format: MM slash DD slash YYYY
