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.
