Questionnaire

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Questionnaire

Speech, Language or Learning Disabilities

Date________________

Name_______________________________________________

Age_____ Birthdate __________ Sex M____ F_____

Address_____________________________________________

City____________________ State________ Zip __________

Phone _________________

Person completing form________________________________

Relationship to client__________________________________

Name of referring
Doctor, Agency, or Friend______________________________

Their specialty_______________________________________

Address_____________________________________________

Phone _________________

Has the child had any previous testing
either at school or through a private agency?_________

If so, give the name of the agency and the dates tested:

Name_________________________________ Date________

Address____________________________________________

Why is this evaluation being requested?

____________________________________________________

Do other family members have similar problems?__________

FAMILY INFORMATION

FATHER:

Father's Name_______________________________ Age____

Address_____________________________________________

Phone_______________________

Occupation__________________________________________

Business Phone _______________

Employer___________________________________

Cell Phone____________________

Health: __ Good __Fair __Poor

Education completed: _________________________________

MOTHER:

Mother's Name_______________________________ Age____

Address_____________________________________________

Phone_______________________

Occupation___________________________________________

Business Phone _______________

Employer___________________________________

Cell Phone____________________

Health: __ Good __Fair __Poor

Education completed: __________________________________

List all children in the family from the oldest to the youngest:

Name_______________________ Age____Health__________

Is any language other than
English spoken in the home? __________________________

What is your nationality?______________________________

BIRTH HISTORY

Weight of child at birth_________ Was child full term?______

Were there any unusual factors relating to the pregnancy
(such as toxemia, x-ray treatments, RH negative,
German measles, other illnesses, drugs or medication)?

Type of birth:

____ normal ____ induced ____ forceps

____ Caesarean ____ breech ____ premature

DEVELOPMENTAL HISTORY

In early childhood, did the child have any
feeding problems, such as poor control of
sucking, food allergies, digestive upsets, etc? __Yes __No

Describe:____________________________________________

____________________________________________________

Do you feel the child was late or had difficulty in the development of the following behaviors: ____Yes ____No

Sitting	____Yes ____No
Walking	____Yes ____No
Eating solid foods	____Yes ____No
Self-feeding	____Yes ____No
Crawling	____Yes ____No
Self-dressing	____Yes ____No
Standing alone	____Yes ____No
Bladder and bowel control	____Yes ____No

Which hand does the child prefer?______________________

Does the child have any
present problems in eating or sleeping?__________________

Does he/she have any nervous habits?___________________

___________________________________________________

How would you describe your child?______________________

___________________________________________________

Do you believe that your child is now
well coordinated in walking, using his
hands, running, riding a trike or bike, etc.? __Yes __No

MEDICAL FACTORS

Present weight__________ Present Height _______________

Doctor most familiar with child__________________________

Doctor's phone number________________________________

Childhood diseases:

Measles	____Yes ____No
Rheumatic Fever	____Yes ____No
Mumps	____Yes ____No
Chicken Pox	____Yes ____No
Whooping Cough	____Yes ____No
Pneumonia	____Yes ____No
Other	___________________

Current medications:__________________________________

Frequent colds, frequent sore throats?___________________

Allergies, asthma, hay fever, etc?_______________________

Does he tend to breathe with his mouth open?____________

Has the child had any operations?____ Specify:___________

Have tonsils and adenoids been removed?___ When?_______

Has he had any trouble with his ears, such as earaches, infections, evidence of hearing loss?_____________________

Has hearing been tested?_______When__________________

Have his/her eyes been screened?_____ When_____________

Has he/she ever worn glasses
or had any difficulty with his eyes?____ Specify:___________

Optometrist_________________________ Phone___________

Has your child ever had a concussion? ______yes______no

If yes, details:_______________________________________

___________________________________________________

EDUCATION

Present grade_____ Name of School_____________________

Teacher's name______________________________________

Does he/she like school?_______

Does he/she like his teacher?_______

Are any school subjects difficult for him/her?______________

Has he/she ever failed or skipped a grade?________________

What are his/her best subjects?________________________

Have you ever discussed the problems with his/her teacher?_____

Does he attend special classes?________________________
(e.g. speech therapy, language development, reading clinic, etc.)

How does the teacher describe your child's behavior in school?

__ poor work habits
__ does not pay attention
__ does not listen
__ does not use time and materials effectively
__ written work careless
__ does not discipline himself

other_________________________________

What kind of grades does your child receive?

__A's
__A's & B's
__B's
__B's & C's
__C's
__C's & D's
__D's
__D's & F's
__F's
__Inconsistent grades, Describe:_______________________

___________________________________________________

What type of study habits does your child demonstrate?

___________________________________________________

What is your child's two favorite pasttimes? ______________

___________________________________________________

List the schools attended in the last 5 years:______________

____________________________________________________

LANGUAGE DEVELOPMENT

How old was the child when
he/she first started to use words?________

How old was the child
when he/she first made sentences?_______

Does he have a speech problem?_________

Describe:___________________________________________

When did you first notice it?___________________________

If no speech problem now, did he/she ever have one?______

Describe:___________________________________________

Has the child had any help for this difficulty?_______

Place______________________________________________

Dates______________________________________________

Has speech noticeably changed in the last six months?_____

What do you believe is the
main cause of his speech/language difficulty?______________

____________________________________________________

I give my permission for my child to be tested:

X ___________________________________

Do you want a copy of this report sent to any one?________

Who?_______________________________________________

____________________________________________________

BILLING INFORMATION

Who is responsible for the bill?

Name_______________________________________________

Phone Number_______________________

Address_____________________________________________

Employer____________________________________________

Business Address_____________________________________

Business Phone _______________________

Occupation_________________________________________

Insurance forms will be filled out if you provide the form. However, please note that we do not accept assignment and you, NOT THE INSURANCE COMPANY, will be responsible for the charges.

Evaluation fees are payable at the time of the testing unless advance arrangements have been made with this office.

DIRECTIONS TO OUR OFFICE

Merritt Speech & Learning
9951 Atlantic Blvd., Suite 250-A
Jacksonville, Florida 32225

904-721-4122 FAX 904-721-4112

Driving instruction to our offices:

We are located 2 blocks east of the Regency Square Mall on Atlantic Boulevard. We are in the Regency East Office Park at 9951 Atlantic Boulevard.

When you enter the office complex the office will be located directly in front of you. See the map below: