New Client Packet

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

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CLIENT INFORMATION

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? Please enter YES, NO, or 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

Child's birth weight:

Was your child admitted to the NICU?

If so, explain (include length of stay).

Was your child nursed?

If so, until what age?

Was there anything remarkable about your child's early feeding history?

Has your child ever suffered from ear infections?

If yes, how many?

Which ears?

At what age(s)?

Were PE tubes inserted?

If yes, at what age?

Does your child have fluid in his/her ears?

If yes, for how long?

Has your child's hearing been tested?

Where?

When?

What were the results?

Is your child sensitive to certain sounds/pitches (e.g., vacuum cleaners, blenders)?

Does your child cover his/her ears when he/she hears certain sounds? (specify)

Clicking Submit will take you to page 2.