CENTER FOR CHILDHOOD COMMUNICATION
DEPARTMENT OF SPEECH-LANGUAGE PATHOLOGY
SPEECH AND LANGUAGE QUESTIONNAIRE
Please complete and return this questionnaire. The information will be used to assist in the proper scheduling and evaluation of the child. All information will be kept confidential.
Person filling out this questionnaire Jennifer Poley Relationship to child Mother -Phone numberhome-402-817-3807cell-402-610-2149
Who referred you to this facility?Dr. Rebecca Ichord
Please √ appointment type needed: Initial/New Evaluation (never seen by CHOP speech) Re-evaluation (seen by CHOP speech before) XX
Has the child had a hearing test within the past year (circle)? NO
Language(s) spoken in the homeEnglish Interpreter Needed (circle)? NO
Child’s nameWilliam PoleyBirth date 08/03/2002
Address222 Main StreetAge9
Seward, NE 68434SexMale
ParentJode PoleyParent Jennifer Poley
Address222 Main StreetAddress222 Main Street
Seward, NE 68434Seward, NE 68434
Home phone402-817-3807Home phone402-817-3807
Marital status marriedMarital statusmarried
Education BA in HistoryEducation Some College
Occupation ____Network administrator____________Occupationhomemaker/admin. assistant Employer__University of Nebraska, Lincoln___EmployerFaith Lutheran Church Work phone___402-472-7962Work phone 402-643-6116
Cell phone___402-610-2912Cell phone 402-610-2149
Name of child’s physician/practice Dr. Douglas Ebers Phone402-489-3834 Address4501 S. 70th, #110, Lincoln, NE 68516
Primary Insurance Blue Cross Blue Sheild of Nebraska Secondary Insurance
Names, ages and relationships of those living in the child’s home: NameAgeRelationship to child
What are the primary concerns that you have about your child’s speech, language or voice? William had a stroke, following open heart surgery, in September of 2004. We have been coming to CHOP for his evaluations of speech since then, and it is time for him to be re-evaluated. He struggles occasionally with choosing words, and getting sentences to be in the right order. This has not happened a lot in the past, but occurances have increased in the last 6 months.
In which of the following areas does the child seem to have difficulty? Check all that apply. _________Hearing sounds_________Voice difficulties
_________Understanding what others say
_________Saying speech sounds
_________Learning and using new words
_________ Other (Please describe)
As listed above.
Who first noticed the problem(s)? Mother When? Spring of 2011
Apart from speech, language and hearing, are there concerns about the child’s development in other areas (e.g., coordination, play skills, making friends, cooperativeness, self-help skills such as toileting and dressing, general activity level)? Please describe. William is a very perceptive child, and does not have other issues. There are some issues with his small motor skills, and leg weakness, but this is from the stroke and is being addressed.
Was child adopted? NO
Were labor and delivery normal?YESType of delivery? NATURAL Was the child premature? NOLength of pregnancy? 39 weeksBirth weight9 lbs.
Were any of the following used by the child’s mother during pregnancy? Cigarettes NOAlcoholic drinks NO
Prescribed drugMom took antibiotics for infections following appendectomy during pregnancy. Nonprescribed drug tylenol
Did the mother experience any illnesses, accidents or injuries during...