Were there any problems during… Pregnancy Yes No Birth Yes No Has your child had… Frequent coughs, Yes No Ear infections Yes No Mumps Yes No Measles Yes No Chickenpox Yes No Any stay in hospital Yes No Any allergies Yes No Hearing Date of Most Recent Hearing Test Outcome Has your child got/had a hearing difficulty Yes No Are you concerned at the moment about your child’s Yes No hearing? Early Development Approximate Age Sitting Crawling Walking First Words Joining Words Together Toileting Day: Night: Does your have any Yes No difficulties with eating or drinking? Please give details. Has your child ever… Sucked their thumb Yes No Used a Yes No Still use a bottle Yes No Family Please give names and ages of any brothers and sisters Has anyone received Speech and Language Yes No Therapy or had known Speech Problems?
Were there any problems during… Pregnancy Birth Yes No Yes No Has your child had… Frequent coughs, Ear infections Mumps Measles Chickenpox Any stay in hospital Any allergies Yes No Yes No Yes No Yes No Yes No Yes No Yes No Hearing Date of Most Recent Hearing Test Outcome Has your child got/had a hearing difficulty Yes No Are you concerned at the moment about your child’s hearing? Yes No Early Development Approximate Age Sitting Crawling Walking First Words Joining Words Together Toileting Day: Night: Does your have any difficulties with eating or drinking? Yes No Please give details. Has your child ever… Sucked their thumb Used a Still use a bottle Yes No Yes No Yes No Family Please give names and ages of any brothers and sisters Has anyone received Speech and Language Therapy or had known Speech Problems? Yes No
assessment_clinic_checklist_form.docx