Speech-Language Pathology Evaluation Template - Pediatric

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ORTHONET
SPEECH-LANGUAGE PATHOLOGY EVALUATION-PEDIATRIC
Member/ID#:
Insurance Company:
Provider:
Provider #:
Medical Diagnosis:
ICD-9 Code:
Date of Birth:
Age:
Date of Onset:
Date of Evaluation:
Background History:
• Reason for Referral:
• Medical History:
• Developmental Milestones:
• Hearing:
• Dominant Language in the Home:
• Family History of Speech and Language Issues:
• History of Formal Therapy Services:
Formal Assessment:
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
ORTHONET
SPEECH-LANGUAGE PATHOLOGY EVALUATION-PEDIATRIC
Member/ID#:
Insurance Company:
Provider:
Provider #:
Medical Diagnosis:
ICD-9 Code:
Date of Birth:
Age:
Date of Onset:
Date of Evaluation:
Background History:
• Reason for Referral:
• Medical History:
• Developmental Milestones:
• Hearing:
• Dominant Language in the Home:
• Family History of Speech and Language Issues:
• History of Formal Therapy Services:
Formal Assessment:
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
Standardized Test: __________________________________________
Results: Raw Score: ______ Standard Score: ______ %ile: _____ AE: _____
Clinical Observations:
Clinical Findings:
• Oral Motor Examination:
• Language Assessment:
• Vocabulary Assessment:
• Pragmatic Assessment:
• Play Assessment:
• Articulation Assessment:
• Fluency:
• Voice:
• Swallowing Concerns:
Clinical Judgment:
Clinical Summary:
Plan of Treatment:
Long Term Goals:
1.
2.
3.
Short Term Goals:
1.
2.
3.
4.
5.
Requested Visits:
Frequency/Duration of Treatment:
SLP Printed Name:________________________________________________
SLP Signature/License #:___________________________________________

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