Euphonic will be recognized as a comprehensive rehabilitation center that serves the local community with well-trained, motivated, friendly personnel, offering services in speech-language pathology and dietary management that are affordable and accessible.
To help our clients maximize their potential and to enhance quality of life.
• Client-centered care: we recognize that our patients' needs come first.
• Excellence: we are committed to ongoing education and continuous improvement.
• Integrity: all our relationships are based on mutual respect, honesty and ethical practice.
• Innovation: we encourage the discovery and development of new approaches to service delivery.
• Social responsibility: we strive to share responsibility for the well being of our communities.
General Information
Child's Name
*
Today's Date
Date of Birth
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Age
0
Person completing this form
Reason for speech therapy
*
Primary physician
Referring physician
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Related medical diagnosis
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Family History
Name of father
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Occupation
Name of mother
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Occupation
Is the child adopted?
*
Yes
No
If so, At what age?
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List of all family members that live with child
Is there family history of any of the
following
ADHD
Learning Disability
Autism/PDD
Hearing Loss
Stuttering
If Other
Prenatal And Birth History
Were there any complications during pregnancy
*
Yes
No
Comments
Was the pregnancy full-term
*
Yes
No
Comments
Were any medications taken during pregnacy
*
Yes
No
Comments
Were labor and delivery normal
*
Yes
No
Comments
Birth weight
*
Medical History
Has Your child had any other problems
Meningitis
*
Yes
No
Details
Chicken Pox
*
Seizures
*
Yes
No
Details
Head Trauma
*
Yes
No
Details
Ear Infections
*
Yes
No
Details
Cleft Palate
*
Yes
No
Details
Visual Problems
*
Yes
No
Details
Hearing Problems
*
Yes
No
Details
Other
Growth And Development
Roll over from stomach to back
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Comments
Roll over from back to stomach
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Crawl
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Sit independently
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Walk holding on to furniture
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Walk independently
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Comments
Start babbling
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Comments
Speak first word
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Speak in 2-word phrases
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Comments
Speak in sentences
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Comments
Educational History ( Only if relevant)
Does Your child attend school?
Yes
No
If so, where
What grade
Has your child ever repeat a grade?
Yes
No
If so, What grade?
Does your child recieve special education or therapy services in school?
Yes
No
If so, please provide details
What are your child's favourite activities?
What are your goals for your child?
Are there any other issues that we should be aware of?