Has your child’s hearing been tested? Select Yes No

Date of last hearing test

Results of last hearing test

Does your child have a history of ear infections? Select Yes No

How often do they / did they get infections?

Grommets? Select Yes No

Speech and Language Development

Age when first:

Babbled

Said words

Joined 2 words together

Joined 3 words together

Current Communication Skills

How does your child communicate their needs to other people?

How easy/difficult is it for familiar people (e.g. family members) to understand your child’s

How easy/difficult is it for unfamiliar people (e.g. shop assistants) to understand your child’s speech?

How well can your child follow simple instructions?(e.g. ‘Get your shoes’)

How well can your child follow more complex instructions?(e.g. ‘Put the wrapper in the bin then close the door’)

Play

Favourite toys and games:

Does your child like to interact with others when he/she plays?

Educational History

Social/personal situation

Previous assessments

Strengths and Weaknesses

Personal care skills eg. dressing, eating & grooming

Family's concerns

Any other information you feel would help in your child’s assessment