SLP Parent Questionnaire

Center of Development www.developmentaldelay.net

931-372-2567

SLP Parent Questionnaire

In order to allow more time to the assessment of your child, it would be appreciated if you would complete the following information.

Child's Name: Date of Birth: Grade:

Social Security Number: Insurance ID:

Parents or Guardian Name(s):

Home Address:

Phone:

School and address: Grade:

Teacher: Special Education Teacher:

Psychologist:

Therapist(s) please specify where, how long and how often therapy performed:

Occupational:

Physical:

Speech:

Medical Doctor(s): Phone#

Any Precautions such as SEIZURES, Special Diet, etc? :__________________________________

_________________________________________________________________________________

Developmental History

Birth weight _____ Lbs. ____Oz. Birth order: first child, second, third, more...

Premature? No Yes amount premature

Normal delivery Caesarean Forceps

Medicated or Natural Birth:____________________________________________________________

Any complications baby?______________________________________________________________

Any complications mother?____________________________________________________________

Normal weight gain (baby)? No Yes

Did child crawl on hands and knees? No Yes

Did child bottom shuffle instead of crawling ? No Yes

At what age did child: crawl (on belly)_______ creep (on hands and knees)_______

were these patterns normal?___________________________________________________

walk: ___Yrs ____Mo first words: ___Yrs ____Mo first sentence: ____Yrs ____Mo

button clothes: ___Yrs ___Mo tie shoes: ___Yrs ___Mo use scissors:____ Yrs ____Mo

definitely become left or right handed: ____Yrs ___Mo use zipper ______Yrs ____ Mo

feed self with spoon_____________ feed self with fork__________ dress alone:____________

Child's preferred hand: left right

Did child have any severe reactions to any immunizations? No Yes

Any change in behavior after immunizations? No Yes

Child's coordination normal for age? No Yes

Does child/student have difficulty with motor coordination, fine motor movements, self help?__________________________________________________________________________
Does child have any dislikes related to touch, textures, movement, muscle tone or other sensory issues?__________________________________________________________________________

Does child crave excessive amounts of movement, touch, or have other difficulties with sensations?
__________________________________________________________________________________________

Additional information on medical history, development, and coordination:
____________________________________________________________________________________________
__________________________________________________________________________________________

General Health

Medical diagnosis(s):_________________________________________________________________
_________________________________________________________________________________

Any serious illness requiring hospitalization? No Yes
details:___________________________________________________________________________

_________________________________________________________________________________

Any medications: No Yes Please list with amounts:
__________________________________________________________________________

Any recurrent ear problems? No Yes How many infections per year: ________________________

Any tubes in ears? No Yes at age:__ Yrs ___Mo

Any high fevers (105+) for more than 48 hrs? No Yes

Speech and Language Development

Has your child had his/her hearing screened? Yes No If yes, were the results Pass or Fail

Any family history of hearing difficulties/surgeries? Yes No If yes, please explain
_______________________________________________________________________________________________
___________________________________________________________________

Any family history of speech/ language difficulties? Yes No If yes, please explain
_________________________________________________________________________________________________
_________________________________________________________________

Any family history of eating/swallowing difficulties? Yes No If yes, please explain __________________________________________________________________________________________________________________________________________________________________

What are your speech/language/eating goals for your child? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Visual History

First comprehensive eye exam (not school screening)? __Yrs ___Mo

Most recent eye exam date? __________

Were spectacles prescribed? No Yes

Any eye patching prescribed? No Yes, how long: __Yrs ___Mo

Any eye surgeries? No Yes

Does one eye turn in or out? No Yes, first noticed when (eg eating, drawing, reading):_________________________________________________________________________

Any excessive eye rubbing? No Yes

Does child turn head when reading or writing? No Yes

Does child have difficulty with (please explain):

Reading:__________________________________________________________________________

Writing:__________________________________________________________________________

Spelling:__________________________________________________________________________

Math:____________________________________________________________________________

Favorite subject or activity:__________________________________________________________________________

Any additional questions or concerns:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Guardian's Signature__________________________________________

Date:____________________________________

Please fill out attached Sensory Processing & Motor Control Questionnaire as well if attached!

Release for Center of Development, PLLC

(Dr. Jason Clopton, Heidi Clopton, OTR/L, Carolyn Bennett, OTR/L Barbara Barlow, COTA, Terri Lee Gleason, OTR/L, Lisa Wood, COTA, Shelley Gardner, PT, Kathryn Gregory CCC-SLP, or those specified by this office) under HIPPA guidelines to record and review any and all patient examination or therapy sessions for the exclusive purpose of:

Parent review, patient review, case studies, presentations to other medical or medical related professionals, documentation or other purposes. (This information will not be used or sold under the HIPPA guidelines and our office privacy rules)

Date:_____________________

Signature of patient (or guardian if minor):________________________

Written name of patient:______________________________________

Written name of guardian:____________________________________

Witness:__________________________________________________

Center of Vision Development, PLLC
Centers of Development, PLLC
1080 Neal Street Suite 300
Cookeville, Tennessee 38501
(931) 372-2567

ACKNOWLEDGMENT OF PRIVACY POLICY AND PRACTICES

I understand that in an attempt to protect the privacy of my identifiable health information, Center of Vision Development and Centers of Development has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purposes of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the CENTER OF VISION DEVELOPMENT and CENTERS OF DEVELOPMENT Privacy Policy & Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.

I have read, understand and acknowledge the Privacy Policy & Practices of Center of Vision Development, PLLC and Centers of Development, PLLC.

This notice is effective as of _______________________ . This authorization will expire seven years after the date on which you last received services from us.

____________________________ ______________________________

Patient or parent Signature Patient Written Name

__________________________________________

Date

_______________________________________

Authorized Provider Representative

Pediatric Occupational Therapy, Physical Therapy and Behavioral Therapies

931-372-2567 toll free 1-877-372-2567 www.developmentaldelay.net email [email protected]

MD Orders for:

Occupational Therapy, Speech and Language Therapy, or Behavior Therapy Evaluation and Treatment

Patients Name:

Address:

Phone Number:

Medical Diagnosis:

ICD-9 Codes:

MD Order (to be filled out by Primary Care Physician) for OT, SLT, or BT evaluation and treatment: ______________________________________________________________________________________________________________________________________________________________________________

MD Signature: ________________________ Date: _______________

PIN#_____________________NPI______________Medicaid________

Authorization # _____________________________________________

MD Address: ______________________________________________

MD Phone #: _______________________________________________

Please fax these orders to COD at: 931-372-2572 and the insurance company to help with coverage and pre-authorization of Occupational Therapy, Speech and Language Therapy, or Behavior Therapy evaluation and treatment. Thank you!

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