Pediatric Speech Intake Form CARE PROVIDERSPRENATAL & BIRTH HISTORYCHILD’S INFORMATIONChild’s GenderMaleFemaleOtherCHILD’S MEDICAL HISTORYDoes your child have a history ofChronic colds/respiratory infectionsChronic ear infectionsAsthmaAllergiesHigh feverInfluenzaDEVELOPMENTAL HISTORYAt what age did your child begin doing the following activities: CONSENTI verify that the above information is correct and true.*Consent for TreatmentI verify that I have read the Consent for Treatment in it’s entirety and agree to all. *EmailSubmit Please enable JavaScript in your browser to submit the form Serving the Portland Metro area in-person, or via teletherapy anywhere in Oregon.
