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Please Describe Speech Concerns:
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Family history of speech, hearing, learning:
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Has patient had any of the following:
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Fine or gross motor skill concerns?
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In the first 2 years of life, were any present:
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Has patient ever been diagnosed with:
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Is patient understood by familiar people?
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Is patient understood by Unfamiliar people?
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What does patient do if not understood?
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What do others do if cannot understand patient?
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Communication behavior is characterized by:
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What is patients communication strengths?
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Does patient:
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What are your primary concerns?
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Does patient play appropriately with toys?
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What kind of toys does patient play with?
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School:
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Grade:
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Teacher:
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Phone:
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School SLP:
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IEP at School?
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Any concerns on ability to learn or remember?
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Does patients teacher have concerns?
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Does patient listen while you read stories?
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Is it easy to change or stop activity?
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If no, how long will patient attend to story?
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Share patients learning strengths:
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What are a few of the patients interests?
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What would you like to see patient accomplish?
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Any medical precautions we should be aware of?
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Primary Care Physician:
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Phone:
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Address:
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Fax:
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Neurologist:
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Phone:
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Address:
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Fax:
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Psychologist:
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Phone:
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Address:
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Fax:
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Other:
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Phone:
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Mother's Name:
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Email:
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Address:
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Daytime Phone:
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Alternate Phone:
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Father's Name:
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Email:
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Address:
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Daytime Phone:
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Alternate Phone:
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Insurance subscriber:
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Insurance subscriber date of birth:
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