Printable/PDF: Nice Speech Lady Intake- PEDIATRIC DEEPER COMMUNICATION QUESTIONNAIRE, VERY YOUNG
Name: ____________________________________DOB: _________ Age:______
PEDIATRIC DEEPER COMMUNICATION QUESTIONNAIRE (VERY YOUNG)
Your name: ______________________________________________________________
Your relationship to your child:____________________(Legal guardians, please bring documents):
When at home, the child spends most of the time with: _____________________(role).
Also, _____________ of the time is spent with ______________ (role)
_____________ of the time is spent with ______________ (role)
When saying words, my child says these categories the most (please list all details):
- Clothes:
- Food:
- Names:
- Toys/animals:
- Parts of the body:
- Greetings/Farewells:
- General “catch phrases”:
Please fill out the details on your child’s ability to:
- Copy speech sounds:
- Says words of parents, other family:
- Points to parts of the body, if asked:
- Turns and looks at sounds of others:
- Use any gestures to communicate:
- Says any common words (“shoe” or “drink”):
- Play with toys:
- Say speech clearly, when produced (understandable):
- Follow simple, every day directions, such as “come here,” etc.
- Sounds that are produced which are typically developed earlier: /m, d, n, t/:
- Sounds that are produced which are typically developed later: /g, k, s/:
- Ability to produced sounds, when desired, smoothly:
- Put words together in phrases which are expected (“goodbye, let’s go”):
- Put words together in other phrases (“blue car,” etc.):
- Focus and engage, as age-appropriate:
- Keep using words or other communication skills that are learned:
My child has the following siblings:
Other family dynamics:
Most of the day is spent with the following on weekdays:
___________________(family member) ____hours/day
Most of the day is spent with the following on weekdays:
___________________(other caregiver) ____hours/day
___________________(other __________________) ____hours/day
Most of the day is spent with the following on weekends:
___________________(family member) ____hours/day
___________________(other caregiver) ____hours/day
___________________(other __________________) ____hours/day
Other:__________________________________________________________________
When at home, my child usually spends time performing:
_______ traditional/non-electronic toys (alone)
Of this time, ________ weekdays; _________weekends.
_______ traditional/non-electronic toys (with others)
Of this time, ________ weekdays; _________weekends.
_______ electronics use (TV, ipads, electronic games), alone
Of this time, ________ weekdays; _________weekends.
_______ electronics use (TV, ipads, electronic games), with others
Of this time, ________ weekdays; _________weekends.
_______ Looks at books, alone
Of this time, ________ weekdays; _________weekends.
_______ Listening to out-loud reading, with others
Of this time, ________ weekdays; _________weekends.
Languages spoke to my child include:
(please circle the environment/environments, list the percentage if if differs, add any other notes)
English: home school community other/family _________
Spanish: home school community other/family _________
Other: home school community other/family _________
________________________________
Other: home daycare/school community other family other
Anything else to add: ______________________________________________________
______________________________________ ______________________
Signature Date
I hope this is helpful to you, and thanks for visiting.
Wilson Nice is the owner of Nice Speech Lady, a medical SLP platform for functional, practical and evidence-based SLP resources.
Nice has been publishing complimentary tools for SLPs since February of 2018.
She currently serves patients at her hybrid clinic in Socorro, New Mexico, Nice Speech Lady.
(Disclosure: friend of Nice Speech Lady)