New Client Packet

Please complete the following forms prior to your evaluation or first session at The Kids' Communication Center.

Page 2

CLIENT INFORMATION

Re-enter child's full name:

Does your child seem under-reactive to loud sounds (e.g., ambulance)?

Is your child on any medications? (specify)

Does your child have any allergies? (specify)

Did your child ever suffer from reflux?

Were any medications prescribed?

Explain your child's typical eating habits.

Does your child crave food?

If yes, please list.

Does your child have any food allergies?

Yes

Never tested

If yes, descibe.

When eating, does your child prefer specific textures (e.g., mushy, crunchy), tastes (e.g., sour, sweet, bland), or temperatures (e.g., hot, cold)?

What is the texture of your child's stools (liquid/formed/paste)?

Please provide examples of regularly-consumed foods that are:

Mushy

Chewy

Sweet

Cold

Crunchy

Sour

Bland

Hot

Please describe a typical breakfast.

Please describe a typical lunch.

Please describe a typical dinner.

Please describe typical snacks.

Does your child drink from an open cup?

Use a straw?

Does your child use a pacifier?

At what age did he/she stop?

Does your child suck his/her thumb?

Does your child eat from a fork?

At what age did he/she stop?

Spoon?

Does you child feed him/herself with a fork?

Does you child drool?

Does your child put toys and fingers in his/her mouth?

Can your chid blow bubbles?

Can your child blow whistles?

Clicking Submit will take you to page 3.