Sometimes, medical SLPs who focus on providing speech services to adults may find themselves in situations where a pediatric or adolescent patient referral is received. Other adult patients may benefit from some of these tools, depending upon the situation.
Included: a five-page pediatric case history form and four versions of PROM (patient reporting outcome measures) for adolescents/other-age groups vs. caregiver/educator perspectives), each for initial evaluations and reassessments.
printable/PDF version: Nice Speech Lady ASSESSMENT AIDE: Pediatric/Adolescent Intake Tools & Beyond
This form provides printable mechanisms for the following, during the intake process (associated pages referenced):
- Nice Speech Lady ASSESSMENT AIDE: Pediatric/Adolescent Case History Tool
- Nice Speech Lady ASSESSMENT AIDE: Adolescent/Other-Age Group PROM, Caregiver/Educator
- Nice Speech Lady ASSESSMENT AIDE: Adolescent/Other Age-Group PROM
- Nice Speech Lady RE-ASSESSMENT AIDE: Adolescent/Other-Age Group PROM, Caregiver/Educator
- Nice Speech Lady RE-ASSESSMENT AIDE: Adolescent/Other Age-Group PROM
- ASSESSMENT-AIDE Quick-Reference Guide for PROM
Due to the various pediatric/adolescent/other-age group choices in this assessment aide set document, clinicians can choose to print each form individually through printer setting preferences.
Nice Speech Lady ASSESSMENT AIDE: Pediatric/Adolescent Case History Tool
Child’s Name:
DOB:/Age:
PEDIATRIC INTAKE
Your name/role in the child’s life:
Address:
Phone number:
Your email:
Alternate contact person/info:
Preference for appointment reminders (please circle): TEXT/RECORDED PHONE CALLS
Why was your child referred for a speech evaluation?
Past medical history/major diagnoses:
History of previous SLP services:
Please explain:
The previous focus –
The previous types of tasks that were helpful –
The previous results –
The length of time in therapy (number of months/years) –
The frequency (how many times a week) —
Siblings:
How many/other family information:
Primary language at home?
Other languages in the patient’s circle, and extent:
Biggest concern/need:
Has your child been evaluated by other professionals (occupational therapist, physical therapist, psychologist, medical specialists such as psychiatry, ENT, GI, neurology, etc.)?
Yes/No
Details/concerns:
Please describe the pregnancy and birth processes (including any complications, etc.):
Other:
Please list the details if your child has been diagnosed with any medical conditions.
Please list any accidents, illnesses, surgeries, or other factors.
Please list any suspected conditions that have not been diagnosed.
Has your child had any ear infections? If so, how many?
Please list any medications your child currently takes (or has a history of taking).
Please describe your child’s communication skills:
How much of your child’s speech do you understand?
From a 0% to 100% range, in general:
What is the most prominent issue you see in understanding their speech articulation?
How much of your child’s speech do others understand?
From a 0% to 100% range, in general:
What is the most prominent comment you hear from others on understanding your child’s speech?
Date of last physical examination; Details:
Date of last vision screening or full vision examination (circle one, please). Results:
Date of last hearing screening or full audiological evaluation (circle one, please). Results:
School info:
Name/Address:
Grade currently in:
School challenges that you observe:
Positives the school is implementing:
Your child’s strengths at school:
Did your child attend Pre-K?
Speech or other services presently offered in school:
If your child is in school, are there any concerns about academic performance (e.g., reading, writing, different subject areas)? Yes/Maybe/No Other details:
How does your child feel about school?
Please describe current reading/writing skills:
Age your child began to:
Sit:
Walk:
Run:
Age for speaking a first word:
Age of starting to put words together:
Start using sentences:
Other comments about development, thus far:
How does your child operate at school (strengths/challenges):
Does your child demonstrate frustration when not understood? Yes/No
If yes –
Frustration is displayed on a 1-10 scale with 10 “being the most frustration possible”:
How often this tends to occur: Other details:
Does your child engage in eye contact during communication? Yes/Sometimes/No
Please describe the importance of eye contact in your family culture:
When given choices, does your child prefer to play …. (circle one) Alone/Others/Combination/Other Details:
Your goals for your child:
In general, I would like my child – within 3 months – to:
In general, I would like my child – within 1 year to:
Specific to speech concerns, I would like my child – within 3 months to:
In general, I would like my child – within 1 year – to:
Positives currently in place – to help your child achieve goals:
Requests in how the therapy could be conducted (to support making the experience effective for your child/the home environment)?
What are some of your child’s favorite activities, subjects, and interests?
Preference for treatment (circle) In-person/Virtual/Combination
Willingness for home practice tasks (circle) None/Low/Medium/High
Other thoughts about the idea of home practice tasks:
Preference for home practice tasks (circle) paper documents/videos/other:
Preference for frequency of visits for treatment:
Other preferences:
Is there anything else important to add that was not asked about?
Thank you for filling out this form.
Nice Speech Lady ASSESSMENT AIDE: Adolescent/Other-Age Group PROM (Caregiver/Educator)
Please read these areas of difficulty. Please circle the number in the 0-10 range, with:
0 = no difficulties
1 = very mild difficulties
2 or 3 = mild difficulties
4 = mild to moderate difficulties
5 or 6 = moderate difficulties
7 = moderate to severe difficulties
8 or 9 = severe difficulties
10 = profound difficulties
“Becomes frustrated when others cannot understand attempted speech.”
“Avoids talking, in general.”
“Has difficulty producing speech sounds that others make.”
“Stutters, in general.”
“Has difficulties with schoolwork, in general.”
“Has difficulties spelling.”
“Has difficulties writing.”
“Has difficulties following conversations in a group.”
“Has difficulties with understanding multiple-meaning words.”
“Has difficulties in understanding figurative language (“turned over a new leaf”).
“Has difficulties in understanding jokes.”
“Has difficulties understanding differences in others’ facts and opinions.”
“Has difficulties following complex instructions (unusual words/multi-step tasks).”
“Has difficulties in word-finding for single words.”
“Has difficulties in word-finding for producing simple sentences.”
“Has difficulties in word-finding for producing longer sentences.”
“Has difficulties thinking of words that are desired to be said, in general.”
“Has difficulties in using language to provide information to others.”
“Has difficulties with grammar.”
“Has difficulties in using multiple-meaning words.”
“Has difficulties in using figurative language (“turned over a new leaf”).
“Has difficulties in communicating facts vs. own opinions.”
“Has difficulties in organizing thoughts and ideas.”
“Has difficulties defining words.”
“Has difficulties answering others’ “who, what, where, when, why & how” questions.”
“Has difficulties asking “who, what, where, when, why & how” questions).”
“Has difficulties in participating in long or complex conversations.”
“Reluctant to answer questions at home.”
“Reluctant to answer questions in the classroom.”
“Has difficulties with vocabulary, as compared to typically-developing peers.”
“Has difficulties explaining what they have learned at school.”
“Has difficulties analyzing another person’s viewpoint.”
“Has difficulties navigating various social situations.”
other:
Nice Speech Lady ASSESSMENT AIDE: Adolescent/Other Age-Group PROM
Please read these areas of difficulty. Please circle the number in the 0-10 range, with:
0 = no difficulties
1 = very mild difficulties
2 or 3 = mild difficulties
4 = mild to moderate difficulties
5 or 6 = moderate difficulties
7 = moderate to severe difficulties
8 or 9 = severe difficulties
10 = profound difficulties
“I become frustrated when others cannot understand my speech.”
“I avoid talking, in general.”
“I have difficulty producing speech sounds that others make.”
“I stutter, in general.”
“I have difficulties with schoolwork, in general.”
“I have difficulties spelling.”
“I have difficulties writing.”
“I have difficulties following conversations in a group.”
“I have difficulties with understanding multiple-meaning words.”
“I have difficulties in understanding figurative language (“turned over a new leaf”).
“I have difficulties in understanding jokes.”
“I have difficulties understanding differences in others’ facts and opinions.”
“I have difficulties following complex instructions (unusual words/multi-step tasks).”
“I have difficulties in word-finding for single words.”
“I have difficulties in word-finding for producing simple sentences.”
“I have difficulties in word-finding for producing longer sentences.”
“I have difficulties thinking of words that I desire to say, in general.”
“I have difficulties in using language to provide information to others.”
“I have difficulties with grammar.”
“I have difficulties in using multiple-meaning words.”
“I have difficulties in using figurative language (“Turned over a new leaf”).
“I have difficulties in communicating facts vs. my own opinions.”
“I have difficulties in organizing thoughts and ideas.”
“I have difficulties defining words.”
“I have difficulties answering others’ “who, what, where, when, why, how” questions.”
“I have difficulties asking “who, what, where, when, why & how” questions).”
“I have difficulties in participating in long or complex conversations.”
“I am reluctant to answer questions at home.”
“I am reluctant to answer questions in the classroom.”
“I have difficulties with vocabulary, as compared to others my same age.”
“I have difficulties explaining what I have learned at school, to others.”
“I have difficulties analyzing another person’s viewpoint.”
“I have difficulties navigating various social situations.”
other:
Nice Speech Lady RE-ASSESSMENT AIDE: Adolescent/Other-Age Group PROM (Caregiver/Educator)
Previous dates:
Please read these areas of difficulty. Please circle the number in the 0-10 range, with:
0 = no difficulties
1 = very mild difficulties
2 or 3 = mild difficulties
4 = mild to moderate difficulties
5 or 6 = moderate difficulties
7 = moderate to severe difficulties
8 or 9 = severe difficulties
10 = profound difficulties
“Becomes frustrated when others cannot understand attempted speech.”
“Avoids talking, in general.”
“Has difficulty producing speech sounds that others make.”
“Stutters, in general.”
“Has difficulties with schoolwork, in general.”
“Has difficulties spelling.”
“Has difficulties writing.”
“Has difficulties following conversations in a group.”
“Has difficulties with understanding multiple-meaning words.”
“Has difficulties in understanding figurative language (“turned over a new leaf”).
“Has difficulties in understanding jokes.”
“Has difficulties understanding differences in others’ facts and opinions.”
“Has difficulties following complex instructions (unusual words/multi-step tasks).”
“Has difficulties in word-finding for single words.”
“Has difficulties in word-finding for producing simple sentences.”
“Has difficulties in word-finding for producing longer sentences.”
“Has difficulties thinking of words that are desired to be said, in general.”
“Has difficulties in using language to provide information to others.”
“Has difficulties with grammar.”
“Has difficulties in using multiple-meaning words.”
“Has difficulties in using figurative language (“Turned over a new leaf”).
“Has difficulties in communicating facts vs. own opinions.”
“Has difficulties in organizing thoughts and ideas.”
“Has difficulties defining words.”
“Has difficulties answering others’ “who, what, where, when, why & how” questions.”
“Has difficulties asking “who, what, where, when, why & how” questions).”
“Has difficulties in participating in long or complex conversations.”
“Reluctant to answer questions at home.”
“Reluctant to answer questions in the classroom.”
“Has difficulties with vocabulary, as compared to typically-developing peers.”
“Has difficulties explaining what they have learned at school.”
“Has difficulties analyzing another person’s viewpoint.”
“Has difficulties navigating various social situations.”
other:
Analysis:
Areas which improved:
Areas which declined:
Remained the same:
Has the potential to improve:
Other observations:
Nice Speech Lady RE-ASSESSMENT AIDE: Adolescent/Other Age-Group Perspective PROM
Previous dates:
Please read these areas of difficulty. Please circle the number in the 0-10 range, with:
0 = no difficulties
1 = very mild difficulties
2 or 3 = mild difficulties
4 = mild to moderate difficulties
5 or 6 = moderate difficulties
7 = moderate to severe difficulties
8 or 9 = severe difficulties
10 = profound difficulties
“I become frustrated when others cannot understand my speech.”
“I avoid talking, in general.”
“I have difficulty producing speech sounds that others make.”
“I stutter, in general.”
“I have difficulties with schoolwork, in general.”
“I have difficulties spelling.”
“I have difficulties writing.”
“I have difficulties following conversations in a group.”
“I have difficulties with understanding multiple-meaning words.”
“I have difficulties in understanding figurative language (“turned over a new leaf”).
“I have difficulties in understanding jokes.”
“I have difficulties understanding differences in others’ facts and opinions.”
“I have difficulties following complex instructions (unusual words/multi-step tasks).”
“I have difficulties in word-finding for single words.”
“I have difficulties in word-finding for producing simple sentences.”
“I have difficulties in word-finding for producing longer sentences.”
“I have difficulties thinking of words that I desire to say, in general.”
“I have difficulties in using language to provide information to others.”
“I have difficulties with grammar.”
“I have difficulties in using multiple-meaning words.”
“I have difficulties in using figurative language (“Turned over a new leaf”).
“I have difficulties in communicating facts vs. own opinions.”
“I have difficulties in organizing thoughts and ideas.”
“I have difficulties defining words.”
“I have difficulties answering others’ “who, what, where, when, why, how” questions.”
“I have difficulties asking “who, what, where, when, why & how” questions).”
“I have difficulties in participating in long or complex conversations.”
“I am reluctant to answer questions at home.”
“I am reluctant to answer questions in the classroom.”
“I have difficulties with vocabulary, as compared to others my same age.”
“I have difficulties explaining what I have learned at school, to others.”
“I have difficulties analyzing another person’s viewpoint.”
“I have difficulties navigating various social situations.”
other:
Analysis:
Areas which improved:
Areas which declined:
Remained the same:
Has the potential to improve:
Other observations:
Wilson Nice, SLP, is the owner of Nice Speech Lady, a medical SLP platform for functional, practical and evidence-based SLP clinical resources.
Nice has been publishing complimentary tools for SLPs since February of 2018.
She is a hybrid outpatient clinic owner — serving adults and children, in Socorro, New Mexico.
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