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Child Assessment Form Ages 3-15
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Name
*
First
Last
Birthday
*
Age
*
Today's Date
*
Medical Issues
*
Medications Taking
*
Allergies
*
Previous Clip of Tongue/Lip?
*
Yes
No
If yes, when/where?
Has your child experienced any of the following SPEECH issues?
Frustration with communication
Difficult to understand by parents
Difficult to understand by outsiders
Difficulty speaking fast
Difficulty getting words out / groping for words
Trouble with sounds (which?)
Speech delay (when?)
Stuttering
Speech harder to understand in long sentences
Mumbling or speaking softly
“Baby Talks” or uses baby voice
Speech therapy (how long?)
Elaborate where needed/ Other
baby? experienced the
Has your child experienced any of the following FEEDING issues?
Frustration when eating
Difficulty transitioning to solid foods
Slow eater / doesn’t finish meals
Small appetite / trouble gaining weight
Grazes on food throughout the day
Packing food in cheeks like a chipmunk
Picky eater/ with textures (which?)
Choking or gagging on food
Spits out food
Won’t try new foods
Constipation
Reflux (medicated or not)
Affects family dynamics (can’t eat out, etc.)
Elaborate where needed/ Other
Has your child experienced any of the following NURSING OR BOTTLE FEEDING issues as a baby?
Painful nursing or shallow latch
Poor weight gain
Reflux or spitting up
Gassy (tooted a lot) as baby
Milk leaked out of mouth / messy eater
Poor milk supply
Nipple shield needed for nursing
Clicking or smacking noise when eating
Cried a lot / colic as baby
Elaborate where needed/ Other
Has your child experienced any of the following SLEEP issues?
Sleeps in strange positions
Sleeps restlessly / kicks / moves a lot
Wakes easily or often
Wets the bed
Wakes up tired and not refreshed
Grinds teeth while sleeping
Sleeps with mouth open
Snores while sleeping (how often)
Gasps for air or stops breathing (sleep apnea)
Elaborate where needed/ Other
Has your child experienced any of the following LIP-TIE or OTHER related issues?
Difficult or fights to brush top teeth
Top teeth don’t show when smiling
Gap between two front teeth
Cavities on front teeth
Trouble eating from a spoon/ flips spoon over
Trouble with B,P,M or W sounds
Difficulty breathing through nose
Neck or shoulder tension or pain
TMJ Pain, clicking, or popping
Headaches or migraines
Strong gag reflex
Prolonged thumb sucking / pacifier use
Mouth open /mouth breathing during the day
Tonsils or adenoids removed previously
Ear tubes previously / lots of ear infections
Hyperactivity / Inattention
Elaborate where needed/ Other
Primary Care Provider
*
Chiropractor/PT/CST
Speech/Feeding Therapist
Other Therapist/Provider
Who referred you to us?
How far away do you live?
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