PARENT INPUT FORM: Speech/Language Developmental History Confidential Sevier County Schools/Department of Special Education/Sevierville, TN Student Information Name ______________________________ Date of birth _______________ Age ______ Form Completed by _____________________________ Date _______________ Parents/Legal Guardian (Check all that apply) With whom does this child live? __Both parents __Father __Stepmother __Stepfather __Other If so, who?_____________________________________ Parents/Legal Guardians Name(s): ______________________________________________________ Address ___________________________________________________________________________ Home phone __________________ Work phone _______________Cell phone __________________ List names and relationships of people at home: ___________________________________________ __________________________________________________________________________________ Are there any languages other than English spoken at home? ___Yes ___No If yes, what languages? ________________________ By whom? ______________________ How often? ________________ Areas of Concern (Check all that apply) Behavioral/emotional Slow development Immature language usage Difficulty understanding language Speech difficult to understand Vision problems Slow motor development Stuttering Listening Health/medical Uneven development Other ___________ Why are you requesting this evaluation? ___________________________________________________ ____________________________________________________________________________________ Did anyone suggest that you refer your child? Yes No If yes, name and title: _____________________________________________________________ Has a physician, psychologist, speech pathologist, or other diagnostic specialist evaluated your child? Yes No If yes, was a diagnosis determined? Yes No Please explain: _________________ _____________________________________________________________________________________ Preschool History (Check all that apply) Preschool/daycare programs attended: Name ______________________________Address_________________________Dates______________ Name ______________________________Address_________________________Dates______________ List any special services that your child has received (e.g. Head Start, therapy, etc.): Type of service ______________________Age_____Dates___________School/agency_______________ Type of service ______________________Age_____Dates___________School/agency_______________ If your child has attended a preschool or daycare and problems were discussed with you about his/her behavior, explain what was tried and if you think it worked: ______________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Page 2 Parent Input Form Developmental History Pregnancy and Birth Which pregnancy was this? 1st 2nd 3rd 4th Other _____ Was it normal? Yes No If no, explain any complications: ___________________________________________________________ Was your child Full term Premature What was the length of labor? __________________________ Was the delivery: Induced? Yes No Caesarean? Yes No Birth weight: ____________Baby’s condition at birth (jaundice, breathing problems, etc.) _____________ ______________________________________________________________________________________ Motor development (List appropriate ages.) ___________________________________________________ Sat alone ____________________ Crawled ____________________ Stood alone ___________________ Walked independently ______________________ Fed self with a spoon ___________________________ Toilet trained: Bladder _____________________ Bowel _______________________ Medical History List any significant past or present health problems (e.g. serious injury, high temperature or fever, any twitching or convulsions, allergies, asthma, frequent ear infections, etc.)________________________________________ __________________________________________________________________________________________ List any medications taken on a regular basis _____________________________________________________ List medical treatments (e.g. PE tubes, inhalers, ear wax removal) ____________________________________ __________________________________________________________________________________________ Speech and Language (List appropriate ages.) ___________________Spoke first words that you could understand (other than mama or dada) ___________________Used two-word sentences __________________Spoke in complete sentences Does the child communicate primarily using speech? Yes No Does the child communicate primarily using gestures? Yes No Is your child’s speech difficult for others to understand? Yes No Does your child have difficulty following directions? Yes No Does your child answer questions appropriately? Yes No Social Development: What opportunities does your child have to play with children of his/her age? __________________________ _________________________________________________________________________________________ What play activities does your child enjoy? _____________________________________________________ Does she/he play primarily ______alone? Or _______ with other children? Does she/he enjoy pretend play? Yes No Do you have concerns about your child’s behavior? Yes No If yes, please explain: __________________ _________________________________________________________________________________________ How do you discipline your child? _____________________________________________________________ Thank you for providing the above developmental information about your child. Please return to the Speech/language Therapist at your child’s school by _______________________(date). If you have any questions, feel free to contact ________________________at___________________________.