
The developmental history is an important part of your child’s speech, language and hearing evaluation. Please fill out
this form as completely and accurately as possible. Make a note of anything you have questions about and we can
discuss them during your appointment. 

Person completing this form (*) 
Invalid Input 

Relationship to child (*) 
Invalid Input 

Date (*) 
Invalid Input 


I. IDENTIFICATION 

Name (*) 
Invalid Input 

Birth date (*) 
Invalid Input 

Mother’s name (*) 
Invalid Input 

Occupation (*) 
Invalid Input 

Last grade completed in school (*) 
Invalid Input 

Father’s name (*) 
Invalid Input 

Occupation 
Invalid Input 

Last grade completed in school (*) 
Invalid Input 


Names of Brothers and Sisters 


Invalid Input 


Invalid Input 


Invalid Input 


Age 


Invalid Input 


Invalid Input 


Invalid Input 


Speech, Hearing or Medical Problems 


Invalid Input 


Invalid Input 


Invalid Input 


II. AREAS OF CONCERN 

Please describe why you are having your child seen for a speechlanguage evaluation 
Invalid Input 

How does the child usually communicate? (ie: gestures, single words, short phrases, sentences) 
Invalid Input 

Please give two to three examples of the child’s comments that are typical at this time 
Invalid Input 

When did you first become concerned? 
Invalid Input 

Have there been any changes in the condition since you first noticed it? 
Invalid Input 

Is the child aware of the problem? If so, how does he/she feel about it? 
Invalid Input 

Have any other speechlanguage specialists seen the child? 
Invalid Input 

If Yes, what were their conclusions or suggestions? 
Invalid Input 

Have any other specialists seen the child? 
Invalid Input 

If Yes, what type of specialists and what were their conclusions or suggestions? 
Invalid Input 

Did seeing any of the above mentioned specialists help? 
Invalid Input 

If Yes, please explain 
Invalid Input 


Are there any incidences of any of the following conditions among the child’s family and close relatives? 

1. Speech Problems 
Invalid Input 

Please Explain 
Invalid Input 

2. Hearing Problems 
Invalid Input 

Please Explain 
Invalid Input 

3. Learning Disabilities 
Invalid Input 

Please Explain 
Invalid Input 

4. Seizures / Convulsions 
Invalid Input 

Please Explain 
Invalid Input 

5. Intellectual Disability 
Invalid Input 

Please Explain 
Invalid Input 

6. Autism / Spectrum Disorder 
Invalid Input 

Please Explain 
Invalid Input 


III. SPEECH, LANGUAGE AND HEARING HISTORY 

How much did the child babble and coo during the first 6 months? 
Invalid Input 

What were the child’s first few words and at what age were they spoken? 
Invalid Input 

How many words did the child have at 18 months? 
Invalid Input 

When did the child begin to use twoword sentences? 
Invalid Input 

Does the child make sounds incorrectly? 
Invalid Input 

If Yes, which ones? 
Invalid Input 


How well can the child be understood?(Poorly to Very Well) 

By his/her parents 
Invalid Input 

Comments 
Invalid Input 

By his/her siblings and playmates 
Invalid Input 

Comments 
Invalid Input 

By family friends and relatives 
Invalid Input 

Comments 
Invalid Input 

By strangers 
Invalid Input 

Comments 
Invalid Input 

Does the child hesitate, “get stuck”, repeat, or stutter on sounds or words? 
Invalid Input 

If Yes, please describe 
Invalid Input 

How does the child’s voice sound? 
Invalid Input 

Did the development of the child’s speech ever slow down or did he/she ever stop talking? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Does the child imitate words but not use them? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Are there any other languages spoken in the home? 
Invalid Input 

If Yes, which ones, by whom and how often? 
Invalid Input 

How well does the child understand what is said to him/her? 
Invalid Input 

How does the child’s speech compare to those of his/her siblings? 
Invalid Input 

Does the child have ear infections? 
Invalid Input 

If Yes, how often? 
Invalid Input 

Does the child hear adequately? 
Invalid Input 

If No, please describe 
Invalid Input 

Does his/her hearing ability fluctuate? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Has the child ever worn a hearing aid? 
Invalid Input 

If Yes, in which ear, for how long have they worn it, and does it seem to help him/her? 
Invalid Input 


Please check these as they apply to the child 

Cried less than normal amount 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Laughed less than normal amount 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Yelled or screeched to get attention or express annoyance 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Head banging and foot stamping 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Temper tantrums 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Awkward or uncoordinated 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Very alert to gestures, facial expression or movement 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Generally indifferent to sound 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Did not respond when spoken to 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Responded to noises (car horn, phone) but not to speech 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Difficulty using tongue or ‘tongue tied’ 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Large tongue 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Difficulty Swallowing 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Gags or chokes easily 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Difficulty moving mouth 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Drooled excessively 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Food came out nose 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Talked through nose 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Excessive throat clearing 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 

Mouth breathing 
Invalid Input 

Difficulty breathing 
Invalid Input 

If Yes, please explain and give ages if possible 
Invalid Input 


IV. PREGNANCY AND BIRTH HISTORY 

Which pregnancy was this child 
Invalid Input 

Length of pregnancy 
Invalid Input 

Did any illness, disease and/or accidents occur during pregnancy? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Did a blood incompatibility exist between the mother and father? 
Invalid Input 

Age of mother at infant’s birth 
Invalid Input 

Age of father at infant’s birth 
Invalid Input 

Length of labor 
Invalid Input 

Drugs used during labor 
Invalid Input 

Were there any problems at birth, ie: breech, caesarean, fever, etc.? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Were forceps used? 
Invalid Input 

Weight of infant at birth 
Invalid Input 

Child was 
Invalid Input 

Were there any bruises or scars on the infant’s head? 
Invalid Input 

Any other abnormalities of the infant’s head or body? 
Invalid Input 

Did the infant require oxygen following birth? 
Invalid Input 

Was the child “blue” or jaundiced at birth? 
Invalid Input 

Was a blood transfusion required at birth? 
Invalid Input 

Did the infant have a bowel movement before birth? 
Invalid Input 

If you answered Yes to any of the questions above please explain 
Invalid Input 

Were there any problems during the first two weeks of life, ie: health, swallowing, sucking, feeding, sleeping, etc.? If so, please explain: 
Invalid Input 


V. MEDICAL HISTORY 

Is the child currently under the care of a doctor (aside from their primary care physician for general checkups)? 
Invalid Input 

If Yes, please explain 
Invalid Input 

Is he/she taking medication? 
Invalid Input 

If Yes, what type and why? 
Invalid Input 


Please indicate the age at which any of the following occurred and the severity 


Adenoidectomy 

Age 
Invalid Input 


Invalid Input 


Allergies 

Age 
Invalid Input 


Invalid Input 


Asthma 

Age 
Invalid Input 


Invalid Input 


Blood disease 

Age 
Invalid Input 


Invalid Input 


Cataracts 

Age 
Invalid Input 


Invalid Input 


Chicken Pox 

Age 
Invalid Input 


Invalid Input 


Chronic Colds 

Age 
Invalid Input 


Invalid Input 


Convulsions 

Age 
Invalid Input 


Invalid Input 


Crosseyed 

Age 
Invalid Input 


Invalid Input 


Croup 

Age 
Invalid Input 


Invalid Input 


Dental Problems 

Age 
Invalid Input 


Invalid Input 


Diphtheria 

Age 
Invalid Input 


Invalid Input 


Earaches 

Age 
Invalid Input 


Invalid Input 


Headaches 

Age 
Invalid Input 


Invalid Input 


Head Injury 

Age 
Invalid Input 


Invalid Input 


Hearing Problems 

Age 
Invalid Input 


Invalid Input 


High Fevers 

Age 
Invalid Input 


Invalid Input 


Influenza 

Age 
Invalid Input 


Invalid Input 


Mastoidectomy 

Age 
Invalid Input 


Invalid Input 


Measles 

Age 
Invalid Input 


Invalid Input 


Meningitis 

Age 
Invalid Input 


Invalid Input 


Mumps 

Age 
Invalid Input 


Invalid Input 


Muscle Disorder 

Age 
Invalid Input 


Invalid Input 


Nerve Disorder 

Age 
Invalid Input 


Invalid Input 


Orthodontia 

Age 
Invalid Input 


Invalid Input 


Pneumonia 

Age 
Invalid Input 


Invalid Input 


Polio 

Age 
Invalid Input 


Invalid Input 


Rheumatic Fever 

Age 
Invalid Input 


Invalid Input 


Tonsillectomy 

Age 
Invalid Input 


Invalid Input 


Whooping cough 

Age 
Invalid Input 


Invalid Input 

Has the child ever fallen or had a blow to the head? 
Invalid Input 

If Yes, did he/she lose consciousness? 
Invalid Input 


VI. BEHAVIOR 

Did it cause a concussion? 
Invalid Input 

Did it cause Nausea, Vomiting or Drowsiness? 
Invalid Input 

Describe any other illness, injury, operation or physical problem not mentioned above 
Invalid Input 

Did any of the above require hospitalization? 
Invalid Input 

If Yes, please explain 
Invalid Input 


Please indicate which of these apply to the child 

Eating problems 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Sleeping problems 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Toilet training problems 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Difficulty Concentrating 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Stays with an activity 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Needs a lot of discipline 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Underactive 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Overactive / Excitable 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Laughed Easily 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Cried a lot 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Sensitive 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Emotional 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Happy 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Irritable 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Personality Problem 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Gets along with children 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Gets along with adults 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Prefers to play alone 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Other 
Invalid Input 

Explain and give ages if possible 
Invalid Input 

Does the child separate from his/her parents without crying or fussing? 
Invalid Input 

How do you discipline the child? 
Invalid Input 

What are the child’s favorite play activities? 
Invalid Input 


VII. DEVELOPMENTAL MILESTONES 


Please indicate the age at which the following occurred 

Rolled over alone 
Invalid Input 

Sat upright alone 
Invalid Input 

Crawled 
Invalid Input 

Stood alone 
Invalid Input 

Walked unaided 
Invalid Input 

Fed self with spoon 
Invalid Input 

Had first tooth 
Invalid Input 

Dress/undress unaided 
Invalid Input 

Bladder trained 
Invalid Input 

Bowel trained 
Invalid Input 

Toilet trained, waking 
Invalid Input 

Toilet trained, sleeping 
Invalid Input 

What hand does the child prefer? 
Invalid Input 

Has handedness ever changed? 
Invalid Input 

If Yes, at what age? 
Invalid Input 

How would you describe the child’s current physical development? 
Invalid Input 


VIII. EDUCATIONAL HISTORY 


List the schools attended/currently attending, please include nursery/preschools 

Name 
Invalid Input 

Ages 
Invalid Input 

Hours per week 
Invalid Input 

Name 
Invalid Input 

Ages 
Invalid Input 

Hours per week 
Invalid Input 

Current grade 
Invalid Input 

Grades skipped 
Invalid Input 

Grades skipped 
Invalid Input 

Grades failed 
Invalid Input 

Average grades 
Invalid Input 

Best subjects 
Invalid Input 

Is the child frequently absent from school? 
Invalid Input 

If Yes, please explain why 
Invalid Input 

How does the child feel about school and his/her teacher? 
Invalid Input 

What is your impression of the child’s learning abilities? 
Invalid Input 

Has anyone ever thought the child has learning problems? 
Invalid Input 

If Yes please explain: 
Invalid Input 

Describe any speech, language, hearing, psychological, and special education services that have been performed. Include where and how often 
Invalid Input 

Thank you for taking the time to fill out this form, please add any additional information you feel will help us in understanding your child and his/her problem 
Invalid Input 

Captcha (*) 
RefreshInvalid Input 



