Speech & Spoon PLLC PEDIATRIC SPEECH AND FEEDING THERAPY PRE-ORDER HERE Purchase CONCERNED ABOUT YOUR CHILD’S SPEECH AND/OR FEEDING SKILLS? Speech, Language & Feeding Development Questionnaire Thank You! Your questionnaire has been submitted successfully. Speech, Language & Feeding Development Questionnaire Parent Information Your Name Your Email Your Phone Number Child Information Child’s Name Child’s Date of Birth Select Child’s Age Range Select age range 0–3 Months 4–6 Months 7–9 Months 10–12 Months 13–18 Months 19–24 Months 2–3 Years 3–4 Years 4–5 Years 5–18 Years 0–3 Months Milestones Makes cooing sounds Quiets when spoken to Turns head toward sounds Begins social smiling Recognizes caregiver’s voice Latches and feeds without difficulty Shows hunger cues (rooting, hands to mouth) Gains weight steadily Swallows safely without coughing Shows satisfaction after feeds 4–6 Months Milestones Laughs and squeals Responds to name Makes vowel sounds (“ah”, “oh”) Shows interest in people Babbling begins Starts sitting with support Moves tongue side to side Accepts purees Opens mouth during feeding Shows fullness cues 7–9 Months Milestones Babbling with consonants (“ma”, “ba”) Responds to “no” Uses sounds to get attention Shows stranger anxiety Imitates sounds Eats thicker purées Begins finger feeding Drinks from open cup with support Moves food with tongue efficiently Accepts soft solids 10–12 Months Milestones Says “mama” or “dada” with meaning Understands simple commands Tries to imitate words Waves goodbye Points to objects Chews soft table foods Picks up small foods (pincer grasp) Drinks from straw Eats soft fruits and veggies Self-feeds small pieces 13–18 Months Milestones Says 5–10 words Points to show wants Understands simple directions Imitates gestures Follows 1-step directions Eats most textures Bites and chews safely Uses a cup with little spilling Attempts spoon feeding Shows preferences for foods 19–24 Months Milestones Has 50+ words Uses 2-word phrases (“more milk”) Points to body parts Follows 2-step directions Imitates new words Chews a variety of textures Drinks from open cup independently Self-feeds with spoon Tries new foods regularly Demonstrates chewing patterns 2–3 Years Milestones Uses 2–3 word phrases Names familiar things Speech 50% understandable Follows 2-step directions Answers simple questions Eats independently Chews all textures Shows mealtime routines Drinks from regular cup Tries new foods without distress 3–4 Years Milestones Uses 3–4 word sentences Answers “wh” questions Speech 75% understandable Plays with peers Understands basic concepts Eats family meals Uses fork well Shows consistent chewing Tolerates new foods Follows mealtime expectations 4–5 Years Milestones Uses full sentences Tells simple stories Speech 90% understandable Understands time concepts Plays cooperatively Eats full meals independently Cuts food with assistance Tries new foods calmly Drinks independently Identifies hunger/fullness 5–18 Years Milestones Uses age-appropriate grammar Retells stories with detail Understands school vocabulary Maintains conversations Understands figurative language Eats full diet without restrictions Packs/eats meals independently Demonstrates mature chewing Tries new foods Shows age-appropriate mealtime behavior Diagnosis / Concerns Does your child have any diagnoses? Any additional concerns? Submit Questionnaire BOOK A 1:1 CALL
