Cleft Palate Speech Therapy Intake Form
Patient Information
First Name
Last Name
Date of Birth
Age
Gender
Female
Male
Other
Address
Parent/Guardian Name
Contact Number
Email
Medical & Surgical History
Type of Cleft
Cleft Lip
Cleft Palate
Cleft Lip & Palate
Submucous Cleft Palate
Other
Surgical History (Type & Date)
Other Medical Conditions
Speech & Language Concerns
Primary Concern
Previous Speech Therapy (When, Where, Duration, Outcome)
Describe Current Speech (If known)
Languages Spoken at Home
Feeding, Hearing & Development
Any Feeding Issues?
History of Hearing Assessment/Results
Developmental Milestones/Delays
Other Information
Additional Information or Comments