SPEECH-LANGUAGE IMPAIRED CHECKLIST
For Preschool Children
Date: ___________________
Child’s Name: ________________________________________________
Age:__
Person completing this form: ___________________________________
Relationship to Child: __________________________________________
Primary Language spoken by child: _____________________________________
LANGUAGE
Does this child’s use and understanding of spoken language seem typical for his/her age?
yes
no
Does this child ask/answer questions like other same age children?
yes
no
Does this child use appropriate sentence length/structures?
yes
no
Is this child able to follow simple directions during classroom activities?
yes
no
Does this child carry on short conversations typical for his age?
yes
no
Does this child listen/respond to stories read in a small group or at home?
yes
no
Does this child’s ability to understand/use language make it difficult for him/her to participate
fully in classroom activities?
yes
no
No Concerns regarding language.
ARTICULATION
Check if the child is able to produce the following sounds:
p
m
n
k
g
f
w
b
h
Do teachers/classmates have difficulty understanding his/her speech?
yes
no
Does this child’s speech make it difficult for him/her to fully participate during oral
classroom activities?
yes
no
Does this child’s speech make it difficult for him/her to play with or socially interact with
classmates?
yes
no
No Concerns regarding articulation.
STUTTERING
Does this child often repeat syllables, words or phrases more than other children his/her
age?
yes
no
Does this child demonstrate the following physical behaviors?
Eye blinking
facial grimacing
foot tapping
Does this child often seem to have difficulty getting words out?
yes
no
Does this child’s stuttering make it difficult for him/her to talk to teachers and/or
classmates?
yes
no
Does this child seem to avoid speaking at school during some activities?
yes
no
No Concerns regarding stuttering.
VOICE
Does this child’s voice sound unusual for his/her age?
yes
Has this child seen a physician because of his/her voice?
yes
Does this child’s voice make it difficult for him/her to interact with teachers or
classmates?
yes
Does this child’s voice make it difficult for him/her to participate in oral
classroom activities?
yes
PRAGMATIC LANGUAGE
Does this child use appropriate eye contact?
Does this child understand changes in tone of voice?
Does this child understand changes in facial expressions?
Does this child use a variety of facial expressions?
Does he/she use greetings (say “hello”, “goodbye”)?
Does he/she use verbal courtesies (please, thank you, excuse me)?
Does he/she interact with other children?
Does this child flap his hands when he/she is excited?
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no
no
no
no
Does this child demonstrate any of the following behaviors? Check all that apply:
Frequently walks on his/her toes
Lines up toys
No fear of danger
Produces jargon/speaks his/her own language
“Echoes” or repeats exactly
what he hears others say
Flap his/her hands when he/she is excited/upset
ADDITIONAL COMMENTS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PLEASE RETURN FORM TO: ___________________________________________