Case History Questionnaire

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Date

Time

Child's First Name*

Child's Surname*

Date of Birth*

Current Age*

Parent First Name*

Parent Surname*

Home Address*

Suburb*

State*

Postcode*

Phone Number*

Reason for Referral*

Source of referral: (if CDM, please make sure your doctor has signed the documentation and bring to the first appointment)

Has your child ever seen a Speech Pathologist before?*

Family Information

How many siblings?*

Family history of similar issues*

Birth History

Birth History: Pregnancy

Birth History: Delivery

Birth History: Birth Weight

Birth History: Special Needs

Feeding History

Feeding History: Feeding History (Bottle or Breast)

Feeding History: Solids

Feeding History: Problems chewing

Feeding History: Drooling

Thumb Sucking?

Dummy?

If YES (to what age, how many hours per day: bedtime / all day?)

Motor Milestones

Motor Milestones: Crawling

Walked at

Well-coordinated?

Language Milestones

Language Milestones: Babbling

If YES, add details about babbling

First Words at

Sentences at

Have there ever had any concerns re language skills?

If YES, add details about concerns

Has your child’s speech always been clear?

If NO, add details about lack of clarity

Medical History

Medical History: Illnesses/injuries

Medical History: Hospitalisation

Medical History: Medication

Audiology

Audiology: Formal hearing assessment

Audiology: History of ear infections

(Stuttering)Fluency

Please provide details • family history • what type of stutter (does he stutter at the beginning of sentences/]? Does he/she try to say something and nothing comes out?) etc • When is it worse? (e.g. tired/ excited).

Any Additional Comments?

Are you an NDIS participant?*

Please note that we are not an NDIS provider

File Upload

Max. file size: 8 MB.

Drop a file here or click to upload

Want to book a session?
Call us now!

Perth Speech Therapy has an Alfred Cove clinic. This clinic also provides mobile services to schools, day care centres and homes.

Please phone to find the most convenient service for you:

Clinic Location: Alfred Cove

0412 256 656

Case History Questionnaire

Want to book a session?Call us now!

Want to book a session?
Call us now!