2nd Bloggy Bday Giveaway #4: Pediatric Background History Questionnaire!

Giveaway #4

Today, the brilliant Tatyana Elleseff, M.A. CCC-SLP, owner of Smart Speech Therapy, has a wonderful product to offer you for the 4th giveaway of my Bloggy Bday month!  Check out her website via the above link for more information. 

Thank you Communication Station for inviting me to participate in your two year “Blogiversary”. Today I am very excited to contribute by giving away a copy of my new product “Pediatric Background History Questionnaire”. I’ve been blogging quite a bit lately on the topic of obtaining a thorough developmental client history in order to make an appropriate and accurate diagnosis of the child’s difficulties for relevant classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.   Unfortunately due to lack of time as well as appropriate resources many evaluation reports contain the bare minimum of information. This may at time result in lack of knowledge regarding  significant details of the child’s history which may in turn even with targeted assessments still lead to lack of appropriate referrals, diagnoses and relevant targeted interventions. This is why I decided to create a comprehensive 6 page pediatric background history questionnaire was created to assist SLPs, who lack relevant and thorough pediatric questionnaires and intakes with efficient and effective collection of detailed background history information on a variety of general pediatric clients 0-21 years of age. This detailed questionnaire (which is available in pdf format) can be emailed to the parents/caregivers prior to the evaluation to optimize evaluation time and procedures. It is intended to assist SLPs with determining both ‘red’ and ‘green’ development flags in conjunction with testing results in order to make informed decisions regarding the client’s therapy services eligibility. Specific information sections:

  • General demographics
  • Adoption history (if applicable)
  • Detailed prenatal, pregnancy and birth history
  • Medical history
  • Related services history
  • Hearing
  • Auditory processing (if applicable)
  • Development history
    • Motor milestones
    • Oral-motor milestones
    • Speech and language milestones
    • OT needs history
  • Education history
  • Behavior and personality
  • Specific speech language related concerns checklist
  • Additional information summary

pediatric questionnaire You can find it On Sale in my online store HERE or you can enter Communication Station’s giveaway for a chance to win your own copy.

Enter to win below!  Be sure to follow the directions as all invalid entries will be eliminated!

Just leave a comment below on how you could use this product and I’ll choose a random winner Thursday night (7/24/14) after 10pm EST.


Looking for other related materials? Check out helpful links below:

T. Elleseff pic 2Tatyana Elleseff MA CCC-SLP is a bilingual SLP with a full time Rutgers University affiliation as well as privatepractice in Central, NJ. She specializes in working with multicultural, internationally and domestically adopted as well as at-risk children with complex communication disorders. For more information visit her BLOGSTORE, or follow her Facebook page.