Pediatric Background History Questionnaire

This comprehensive 6 page pediatric background history questionnaire was created to assist SLPs with efficient and effective collection of detailed background history information on a variety of general pediatric clients 0-21 years of age. This questionnaire (which is available in pdf format) can be emailed to the parents/caregivers prior to the evaluation to optimize evaluation time and procedures. It is intended to assist SLPs with determining both ‘red’ and ‘green’ development flags in conjunction with testing results in order to make informed decisions regarding the client’s therapy services eligibility.

Specific information sections:

• General demographics
• Adoption history (if applicable)
• Detailed prenatal, pregnancy and birth history
• Medical history
• Related services history
• Hearing
• Auditory processing (if applicable)
• Development history
  • Motor milestones
  • Oral-motor milestones
  • Speech and language milestones
  • OT needs history
• Education history
• Behavior and personality
• Specific speech language related concerns checklist
• Additional information summary