• Long Island Speech Screener Questionnaire

  • Select which Speech Screener you would like to take:*

  • *A tongue thrust is an abnormal, anterior motion and/or placement of the tongue at rest, when speaking, and when swallowing. A tongue thrust can cause articulation errors, chewing/swallowing difficulties, dietary restrictions, and/or problems with the teeth. A tongue thrust can also contribute to temporomandibular joint disorder and/or sleep apnea in adults.

  • **A tongue tie, or a short lingual frenum, is when the band of tissue or “string” under your tongue is restricted or shorter/thicker than it should be. A lip tie, or a short labial frenum, can appear under your upper lip or under your lower lip, in which the band of tissue or “string” under the lip is shorter or more restricted than it should be. A tongue and lie tie can affect the way an individual eats, speaks, swallows, and breastfeeds.

  • Select the age of the patient

  • *

  • Birth-3 Month Assessment

  • Does your baby make cooing sounds?*
  • Does your baby’s cry change for different needs?*
  • Does your baby smile reflexively and at people?*
  • Does your baby become startled by loud sounds?*
  • Does your baby become quiet or smile when you talk to her/him?*
  • Does your baby soothe/calm when hearing your voice and appear to recognize your voice?*
  • Does your baby appear relaxed when feeding, without arching their back or stiffening when feeding?*
  • Does your baby appear content during feeding, without crying or fussing during feedings?*
  • Does your baby have difficulty latching during breast or bottle feeding?*
  • Have you had to trial a variety of formulas with your baby?*
  • Have you had to trial a variety of bottles/nipples with your baby?*
  • Does your baby feed in a timely manner, without taking a long time to feed?*
  • Does your child appear to spit up excessively or have a diagnosis of reflux?*
  • Did your infant pass his/her newborn hearing screening?*

  • 4-6 Months Assessment

  • Does your baby coo and babble when playing alone or with you?*
  • Does your baby make speech-like babbling sounds, like pa, ba, and mi?*
  • Does your baby giggle and laugh?*
  • Does your baby make sounds when happy or upset?*
  • Does your baby explore through vocal play such as growling, squealing, yelling, making ‘raspberries’?*
  • Does your baby move his/her eyes in the direction of sounds?*
  • Does your baby raise his/her arms when a parent reaches toward the child?*
  • Does your baby respond to changes in your tone of voice?*
  • Does your baby notice toys that make sounds?*
  • Does your baby pay attention to music?*
  • Does your baby put his/her hands on the breast or bottle when feeding?*
  • Does your baby bring his/her hands to their mouth?*
  • Is your baby accepting spoon feedings?*
  • Has your baby started accepting a straw or open cup with support?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*

  • 7-12 Month Assessment

  • Does your baby babble in long strings of varied sounds, like ‘mimi upup babababa?’*
  • Does your baby use sounds and gestures to gain and keep one’s attention?*
  • Does your child point to objects and show them to others?*
  • Does your child use gestures like waving bye, reaching for “up,” and shaking his head no?*
  • Does your child imitate different speech sounds?*
  • Does your child say 1 or 2 words, like hi, dog, dada, mama, uh-oh?*
  • Does your child turn and look in the direction of a sound?*
  • Does your child look when you point?*
  • Does your child turn when you call his/her name?*
  • Does your child understand words for common items and people - words like cup, truck, juice, and daddy?*
  • Does your child start to respond to simple words and phrases like “no,” “come here,” and “want more?”*
  • Does your child plays games with you, like peek-a-boo and pat-a-cake?*
  • Does your child listen to songs and stories for a short time?*
  • Does your child attempt to spoon feed him or herself?*
  • Does your child hold a cup with both hands?*
  • Does your child accept mashed and harder/lumpier textures?*
  • Does your child close the lips to clear the spoon?*
  • Does your child accept finger foods?*
  • Does your child begin to self-feed with finger foods?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*

  • 1-2 years old Assessment

  • Does your child’s vocabulary appear to be increasing and expanding regularly?*
  • Does your child correctly use sounds such as p, b, h, and w in words?*
  • Does your child start to name pictures in books?*
  • Does your child ask questions, like “What’s that?”, “Who’s that?”, and “Where’s daddy?”*
  • Does your child raise his/her intonation/inflection when asking a question?*
  • Does your child put two words together, like “more water,” “no bed,” and “mommy ball” (by 18-24 months)?*
  • Can your child point to a few body parts when asked?*
  • Does your child follow 1-step directions, like “Bounce the ball” or “Kiss mommy”?*
  • Does your child respond to simple questions, like “Who’s that?” or “Where’s your ball?”*
  • Does your child listen to simple songs, stories, and rhymes?*
  • Does your child point to pictures in a book when you name them?*
  • Does your child eat a variety of different foods?*
  • Are solid foods your child’s primary nutrition source?*
  • Does your child self feed most of the time?*
  • Does your child chew with their mouth closed?*
  • Does your child present with more control during open cup drinking?*
  • Does your child drink from a straw cup?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Has your child ever been evaluated or received Early Intervention services in the past privately or through the county?*

  • 2-3 years old assessment

  • Does your child have a word for almost everything?*
  • Does your child talk about things that are not in the room?*
  • Does your child use sounds k, g, f, t, d, and n in words?*
  • Does your child use words like in, on, and under?*
  • Does your child use two- or three- words to talk about and ask for things?*
  • Is your child understood by people who know him/her?*
  • Does your child ask “Why?”*
  • Does your child put 3 words together to talk about things?*
  • Does your child understand opposites, like go-stop, big-little, and up-down?*
  • Does your child follow 2-step directions, like “Get the ball and put it in the bucket.”*
  • Does your child understand new words quickly?*
  • Does your child ask wh-questions and yes/no questions?*
  • Does your child raise his/her intonation/inflection when asking a question?*
  • Does your child appear to become frustrated when they are not understood?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing food, or spitting out food?*
  • Does your child speak fluently without repetitions or stuttering present?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Has your child ever been evaluated or received Early Intervention services in the past privately or through the county?*

  • 3-4 years old assessment

  • Does your child answer simple who, what, and where questions?*
  • Does your child use rhyming words, like mat-hat?*
  • Does your child use pronouns, like I, you, me, we, and they?*
  • Does your child use some plural words, like toys, birds, and dogs?*
  • Do most people understand what your child says?*
  • Does your child ask how and when questions?*
  • Does your child put 4 words together, though may make some mistakes? For example, ‘I goed to the park.’*
  • Does your child talk about what happened during the day, using about 4 sentences at a time?*
  • Does your child respond when you call from another room?*
  • Is your child able to identify and label colors like, red, blue, and green?*
  • Does your child identify and label some shapes, like circle, heart, square?*
  • Does your child engage in imaginative play, such as cooking in a toy kitchen, treating a baby boll as a real baby?*
  • Does your child raise his/her intonation/inflection when asking a question?*
  • Does your child understand words for family members, like brother, grandmother, and aunt?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing food, or spitting out food?*
  • Does your child speak fluently without repetitions or stuttering present?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Has your child ever been evaluated or received services privately or through CPSE?*

  • 4-5 Year old assessment

  • Does your child say most speech sounds correctly?*
  • Does your child delete the final sound in words (‘ca’ for ‘cat’)?*
  • Does your child respond to “What did you say?”*
  • Does your child name letters and numbers?*
  • Does your child use sentences that have more than 1 action word, like jump, play, and get. Though they may make some mistakes, like “Zach gots 2 candy, but I got one.”*
  • Does your child tell short stories?*
  • Is your child able to have a longer conversation with others?*
  • Does your child change the way they speak, depending on the listener and place? For example, your child might use short sentences with younger children or may talk louder outside than inside.*
  • Does your child understand words for order, like first, next, and last?*
  • Does your child understand words for time, like yesterday, today, and tomorrow?*
  • Does your child follow longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book.”?*
  • Does your child follow classroom directions, like “Draw a circle on your paper around something you eat.”?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing, or spitting out the food?*
  • Does your child speak fluently without repetitions or stuttering?*
  • Does your child demonstrate appropriate eye contact when speaking or listening to others?*
  • Can your child initiate and/or maintain a conversation for multiple exchanges?*
  • Does your child appropriately share and  take turns when playing with peers?*
  • Can your child attend to a task for a short period of time?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Has your child ever been evaluated or received services privately or through CPSE?*

  • 5-6 years old assessment

  • Does your child recognize and label colors and basic shapes?*
  • Can your child identify and label the letters of the alphabet ?*
  • Does your child know the sounds associated with each letter of the alphabet?*
  • Does your child recite their name, address, and phone number?*
  • Does your child understand basic concepts regarding print, like knowing which way the pages go and that words are read left to right and top to bottom?*
  • Does your child know that a story has a beginning, middle and end?*
  • Does your child remain on an activity for 15 minutes and finish a short assignment?*
  • Does your child respond appropriately when told ‘no’ or when told to do something they may not want to do?*
  • Does your child make plans about how to play, what to build, or what to draw?*
  • Does your child use words to argue and try to reason with people?*
  • Does your child properly use most plurals and pronouns?*
  • Does your child tell stories, jokes, and riddles?*
  • Does your child understand stories, jokes, and riddles?*
  • Does your child talk about and understand opposites and compare items using opposites, like “This purple ball is bigger than the orange ball.”?*
  • Does your child use past and present verb tenses correctly to talk about events that have happened or will happen?*
  • Does your child follow multi-step directions?*
  • Does your child understand why it is helpful to share and get along with other children of the same age?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing, or spitting out the food?*
  • Does your child speak fluently without repetitions or stuttering?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Has your child ever been evaluated or received services privately or through the school district?*

  • 6-7 Years old assessment

  • Is your child developing the skills to reason and think logically?*
  • Is your child able to learn from what he/she hears?*
  • Is your child able to learn from what he/she reads?*
  • Can your child sound out words?*
  • Does your child have a good sense of time, understanding increments of time, days, weeks, months, and seasons?*
  • Does your child understand the relationship between letters and sounds?*
  • Does your child know, use, and understand thousands of words?*
  • Does your child use language to express feelings, persuade others, tell stories, and tell jokes/riddles?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing, or spitting out food?*
  • Does your child speak fluently without repetitions or stuttering?*
  • Does your child understand why it is helpful to share and get along with other children of the same age?*
  • Does your child have a history of ear infections or suffer from chronic ear fluid?*
  • Is your child able to express ideas with written language?*
  • Has your child ever been evaluated or received services privately or through the school district?*

  • 8-10 Years old assessment

  • Is your child intelligible and understood by strangers, friends, and family?*
  • Are your child’s utterances grammatically correct the majority of the time?*
  • Is your child social amongst peers?*
  • Does your child take multiple perspectives and understand different points of view?*
  • Does your child have the language skills necessary to gather information and formulate well-organized opinions and thoughts?*
  • Does your child often misarticulate sounds in words when speaking?*
  • Does your child present with any academic difficulties in the areas of reading, writing, spelling, and/or comprehension?*
  • Is your child on or above grade level for all academic subjects?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing, or spitting out food?*
  • Does your child speech fluently without repetitions or stuttering?*
  • Can your child attend to a task for a prolonged period of time?*
  • Has your child ever been evaluated or received services privately or through the school district?*

  • 11-14 Years old

  • Does your child present with an extensive and evolving vocabulary?*
  • Does your child understand irony and sarcasm?*
  • Does your child use and understand complex grammatical structures?*
  • Does your child use language functionally and adjust their choice of words depending on context and/or audience (ie speak differently to friends versus speaking to a teacher)?*
  • Does your child contribute to conversations and maintain a topic?*
  • Does your child support his/her opinion to formulate an argument?*
  • Does your child present with any academic difficulties in the areas of reading, writing, spelling, and/or comprehension?*
  • Is your child on or above grade level for all academic subjects?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing, or spitting out food?*
  • Does your child speak fluently without repetitions or stuttering?*
  • Has your child ever been evaluated or received services privately or through the school district?*

  • High School Age assessment

  • Does your child appear to present with more mature thinking skills and set goals for the future?*
  • Does your child demonstrate an increased ability to reason, make educated guesses, and understand fact from fiction?*
  • Does your child think about topics in a more abstract way?*
  • Does your child demonstrate reasoning skills and attempt to find solutions to conflict?*
  • Does your child manage time effectively?*
  • Does your child follow long and complicated instructions with many different directions?*
  • Does your child understand figurative language, make predictions, and understand sarcasm?*
  • Does your child tell long and complex stories?*
  • Does your child tell stories that are interesting and engaging to the listener?*
  • Does your child use language to persuade and negotiate with people?*
  • Does your child present with any academic difficulties in the areas of reading, writing, spelling, and comprehension?*
  • Is your child on or above grade level for all academic subjects?*
  • Does your child accept most foods offered as part of a family meal?*
  • Does your child accept foods without gagging, pocketing food, or spitting out food?*
  • Does your child speech fluently without repetitions or stuttering present?*
  • Has your child ever been evaluated or received services privately or through the school district?*

  • Adult assessment

  • Are you (or your loved one) able to name items without hesitation or delay?*
  • Do you (or your loved one) read articles and books with ease and able to recall and retell details from the written material?*
  • Are you (or your loved one) able to eat foods of all textures/consistencies without coughing or difficulty?*
  • Are you (or your loved one) able to drink liquids without coughing or difficulty?*
  • Do you (or your loved one) speak fluently without repetitions or stuttering?*
  • Are you (or your loved one) understood by others 100% of the time?*
  • Can you (or your loved one) move your lips, tongue, and jaw on command to a desired position?*
  • Do you (or your loved one) understand what others are saying?*
  • Can you (or your loved one) share thoughts with ease?*
  • Do you (or your loved one) speak at an appropriate rate, not too slow and not too fast?*
  • Do you (or your loved one) speak at an appropriate volume, not too loud and not too low?*
  • Do you (or your loved one) have an appropriate vocal quality, without the voice sounding hoarse, strained, or raspy?*
  • Are you (or your loved one) able to make plans and set goals?*
  • Do you (or your loved one) have the sensation of a lump in your throat?*
  • Does your (or your loved ones) voice feel tired at the end of a day?*
  • Do you (or your loved one) suffer from temporomandibular joint disorder (TMJD)?*
  • Do you (or your loved one) suffer from sleep apnea?*
  • Do you (or your loved one) feel your tongue resting low in the mouth or against your teeth?*

  • Select age of Patient

  • Is the patient a:*

  • Child Tongue Thrust Assessment

  • Does your child have any trouble producing any of the following sounds: s, z, sh, ch, r, “j” as in ‘juice’ “ge” as in ‘beige,’ or “zh” as in mea“su”re?*
  • Do you see your child’s tongue when they are speaking or when swallowing?*
  • Does your child rest with their mouth open and/or their tongue forward?*
  • Does your child sleep with their mouth open?*
  • Does your child eat at a rapid rate or a very slow rate?*
  • Is your child a picky eater?*
  • Does your child tend to be a messy eater?*
  • Does your child drink excessively when eating?*
  • Does your child tend to pool and/or drool saliva?*
  • Does your child present with grinding, popping, or clenching of their jaw?*
  • Do you have any concerns regarding your child’s teeth?*
  • Following the loss of your child’s “baby teeth” have you noticed that it has taken a long time for the adult teeth to come in?*
  • Has anyone ever told you your child has a short lingual frenum/tongue tie?*
  • Did your child use a bottle or pacifier and/or suck their thumb/finger beyond 12 months of age?*
  • Does your child currently present with any type of oral fixation such as mouthing objects, tongue sucking, nail biting, thumb/finger sucking, excessive lip licking/lip biting?*
  • Does your child have difficulties swallowing pills?*
  • Does your child avoid certain food textures or consistencies?*

  • Adult Tongue Thrust Assessment

  • Does your tongue rest against your teeth?*
  • When you swallow, do you feel your tongue make contact with your teeth?*
  • Do you suffer from temporomandibular joint (TMJ) disorder or have pain in your TM joint?*
  • Do you suffer from sleep apnea?*
  • If you swallow with your lips open, can you see your tongue pushing forward at all?*
  • Have you had braces, yet feel your teeth have shifted?*
  • Have you ever had speech therapy?*
  • Did you, or do you, have trouble producing any of the following sounds: s, z, sh, ch, r, “j” as in ‘juice,’ “ge” as in ‘beige’ or or “zh” as in mea“su”re?*
  • Do you have any difficulties sitting with your lips closed and breathing through your nose?*
  • Do you feel you are a mouth breather?*
  • Do you feel you drink excessively when eating?*
  • Do you currently present with any type of oral fixation such as mouthing objects, tongue sucking, nail biting, excessive lip licking/lip biting?*
  • Do you have difficulties swallowing pills?*
  • Do you avoid certain food textures or consistencies?*
  • Do you present with grinding, popping, or clenching of your jaw?*

  • Picky Eater Assessment

  • Are you concerned that you or your family member avoids certain food textures or consistencies?*
  • Are you concerned that you or your family member drinks excessively when eating?*
  • Are you concerned that you or your family member does not meet the required amount of calorie intake daily?*
  • Are you concerned that you or your family member does not eat enough foods within each food group on a daily basis?*
  • Are you concerned that you or your family member gags when touching, smelling, or trying certain foods?*
  • Are you or your family member losing weight or considered failure to thrive?*
  • Is your or your loved one’s diet limited to mostly carbohydrates?*
  • Are you or your loved one afraid to eat due to a fear of choking?*
  • Will you or your child only eat brand specific food items?*
  • Is this screener for a:

  • Child Tongue Tie/Lip Tie Questionnaire

  • Does your child present with difficulties being understood by his/her parents?*
  • Does your child present with difficulties being understood by outsiders?*
  • Does your child present with difficulties speaking fast?*
  • Does your child present with difficulties being understood when speaking in longer sentences compared to shorter sentences or single words?*
  • Did your child present with a shallow latch or painful breastfeeding?*
  • Did your child present with or currently present with poor weight gain?*
  • Did your child present with or currently present with reflux or excessive spitting up?*
  • Did your child present with or currently present with gassiness as a baby?*
  • Did your child present with or currently present with clicking or smacking noise when eating?*
  • Did your child present with or currently present with excessive crying and/or colic as a baby?*
  • Does your child present with frustration when eating?*
  • Does your child or did your child in the past present with difficulty transitioning to solid foods?*
  • Is your child a slow eater?*
  • Does your child prefer to graze on foods throughout the day rather than eat a full meal?*
  • Does your child present with pocketing of food in the cheeks (like a chipmunk)?*
  • Does your child present with or ever present with choking or gagging on foods?*
  • Does your child present with difficulty or resistance to trying new foods?*
  • Does your child sleep in strange positions?*
  • Does your child present as a restless sleeper, moving a lot in their sleep?*
  • Does your child wake easily and often throughout the night?*
  • Does your child wet the bed?*
  • Does your child wake up tired and not refreshed?*
  • Does your child grind his/her teeth while sleeping?*
  • Does your child sleep with his/her mouth open?*
  • Does your child snore while sleeping?*
  • Does your child gasp for air while sleeping?*
  • Does your child present with neck or shoulder pain/tension?*
  • Does your child present with TMJ pain, clicking or popping?*
  • Does your child suffer from frequent headaches or migraines?*
  • Does your child have a strong gag reflex?*
  • Does your child, or did your child, present with prolonged thumb sucking or pacifier use?*
  • Has your child had his/her tonsils and/or adenoids removed?*
  • Does your child, or has your child, suffered from frequent ear infections?*
  • Does your child have, or has your child had, ear tubes?*
  • Does your child present with hyperactivity or inattention?*
  • Does your child suffer from constipation?*

  • Adult Tongue Tie/Lip Tie Questionnaire

  • Do others have a hard time understanding your speech?*
  • Do you experience difficulty speaking fast?*
  • Do you experience difficulty getting certain words out?*
  • Does your jaw tire when talking or reading aloud?*
  • Is your speech harder to understand in long sentences?*
  • Are you frustrated when eating?*
  • Are you a slow eater?*
  • Do you have a small appetite?*
  • Do you prefer to graze on foods throughout the day?*
  • Do you ever pocket or pack food in your cheeks?*
  • Are you picky when it comes to different food textures?*
  • Do you have difficulty swallowing pills?*
  • Do you ever choke or gag on foods or water?*
  • Do you have trouble breathing through your nose?*
  • Do you present with an open mouth posture during the day or breath through your mouth?*
  • Have your tonsils and/or adenoids been removed?*
  • Do you suffer from sinus issues or have had any sinus surgery?*
  • Have you had teeth extracted for braces?*
  • Have you had jaw surgery in the past?*
  • Do you sleep in strange positions?*
  • Do you move around a lot at night?*
  • Do you wake up easily or often?*
  • Do you feel you get a poor quality of sleep?*
  • Do you wake up tired and not refreshed?*
  • Do you use or have been prescribed a sleep appliance or CPAP machine?*
  • Do you grind your teeth while sleeping?*
  • Do you sleep with your mouth open?*
  • Do you snore while sleeping?*
  • Do you gasp for air or stop breathing when sleeping?*
  • Do you suffer from neck or shoulder pain or tension?*
  • Do you present with TMJ pain, clicking, or popping?*
  • Do you suffer from migraines or headaches?*
  • Do you present with a strong gag reflex?*
  • Did you present with prolonged thumb sucking as a child?*
  • Do you or did you suffer from frequent ear infections or require ear tubes as a child?*
  • Do you suffer from reflux?*
  • Do you suffer from constipation?*
  • Do you present with hyperactivity/inattention?*
  • Do you feel stressed or suffer from anxiety?*
  • Format: (000) 000-0000.

  • *Your score will be displayed once the form is submitted

  • Should be Empty: