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CASE HISTORY FORM
The following case history information is collected to support formal and informal speech and feeding assessments and subsequent speech and feeding therapy session(s).
This is a secure form and meets HIPAA requirements for privacy protection; all submissions will be kept confidential.
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* Indicates required question
Email
*
Your email
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Age
*
Your answer
Preferred Pronouns for Child
He/Him/His
She/Her/Her
They/Them/Their
Other:
Clear selection
Child's current school and grade (if applicable)
Your answer
Please list names, relationships, and ages of all people living in your household:
Your answer
Does this child live in more than one household, e.g. shared custody? If so, please explain:
No
Other:
Clear selection
My child has a history of:
Please select all that apply
Frequent ear infections
Hearing loss
Thumb/pacifier/other sucking
Tongue or Lip Tie / Tongue Thrust
Dental problems
Cleft Lip/Palate or other oral-structural issues
Respiratory problems
Allergies
Gastroesophageal Reflux
Sleeping problems
Feeding problems
Other developmental delays
Other medical issues (you may describe in more detail in "Other", below)
Other:
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