New Pediatric Patient Registration Form

Patient Name

First NameMiddle NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth

MonthDayYear

Date of Evaluation

Date

Referred By:

First NameLast Name

Parent/ Guardian Name

First NameLast Name

Parent Email Address

Primary Language Spoken

Patient Sex

Primary Concern for Appointment

Pediatrician's Name

First NameLast Name

What is the name of the hospital where the patient was born?

What was the mother's length of pregnancy with the patient?

Was the mother's labor:

If yes, which medications or drugs were used?

Patient's birth weight (pounds)

Did any of the following complications apply at time of birth?

Has the patient experienced any of the following medical complications?

Additional Medical History/Symptoms

Is the patient currently taking any medication?

If yes, please list it here

What is your primary concern regarding the patient's speech/language?

If other, please list the concern below.

If no, please explain why you do not believe the patient's speech is normal.

When did the patient say his/her first word?

Approximately how many total words does the patient use?

If yes, please list all food allergies.

If no, please describe the patient's diet.

If not, what seems abnormal about the patient's hearing?

If yes, what type of hearing aid?

If so, what school does the patient attend?

What grade is the patient currently in?

What is the patient's grade point average?

If yes, what type of assistance does the patient receive in school?

New Patient Registration

Patient Information

Medical History

Speech- Language History

Hearing Health History

Academic History