Name: Dr. Judy Sturm and Associates
Address: 77 Bloor St W #1202, Toronto, ON, M5S 1M2, CA
Telephone: +1 4169674212
Price range: $$

Speech Questionnaire Further Speech Assessment
Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5
1. Do you or do others have difficulty understanding your child's speech?
INITIAL SCORE
FOLLOW-UP SCORE
1. Do you or do others have difficulty understanding your child's speech?
INITIAL SCORE
FOLLOW-UP SCORE
3. Uses grunts or screams more than words
INITIAL SCORE
FOLLOW-UP SCORE
4. Lisp
INITIAL SCORE
FOLLOW-UP SCORE
5. Hoarseness
INITIAL SCORE
FOLLOW-UP SCORE
6. Nasal Speech
INITIAL SCORE
FOLLOW-UP SCORE
7. Has frustration when attempting to speak
INITIAL SCORE
FOLLOW-UP SCORE
8. Often uses words with only 1 or 2 syllables
INITIAL SCORE
FOLLOW-UP SCORE
1. Do you or do others have difficulty understanding your child's speech?
INITIAL SCORE
FOLLOW-UP SCORE
9. Seems winded when increasing volume
INITIAL SCORE
FOLLOW-UP SCORE
10. Any difficulty in swallowing
INITIAL SCORE
FOLLOW-UP SCORE
11. Do you think your child might have a stutter
INITIAL SCORE
FOLLOW-UP SCORE
12. Tourette's Syndrome
INITIAL SCORE
FOLLOW-UP SCORE
13. Family History of a speech or language disorder
INITIAL SCORE
FOLLOW-UP SCORE
14. Any speech therapy, If so, how long?
INITIAL SCORE
FOLLOW-UP SCORE
If so, how long?

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Specific Articulation Questions
Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5
1. “hap” for “hat”, “kif” for “kiss”, “fum” for “thumb”, or “bav” for “bath”
(Child replaces a “t, d, n, s, z, th or L” with a “p, b, m, w, f, or v”)
INITIAL SCORE
FOLLOW-UP SCORE
2. “wabbit” for “rabbit”, “yewo” for “yellow” “weg” for “leg”, “pway” for “play”, “wun, for “run”
(Child replaces an “r” with a “w” or an “L” with a “w” or a “y”)
INITIAL SCORE
FOLLOW-UP SCORE
3. “tock” for “sock”, “dump” for “jump”, “pan” for fan”, “bat” for “fat”
(Child replaces a “s, f, v, z, th, j, or h” with a consonant such as “p, b, t, d, k, g”)
INITIAL SCORE
FOLLOW-UP SCORE
4. “sum” for “thumb”, “muhzer” for “mother”
(Child replaces a “p, b, m, w, th, f, or v” with a “t, d, s, z, n, or L”)
INITIAL SCORE
FOLLOW-UP SCORE
5. “gog” for “dog”, “cop” for “top”, “boke” for “boat”, “key” for “tea”
(Child replaces a “t” or a “d” with “k” or “g”)
INITIAL SCORE
FOLLOW-UP SCORE
6. “ship” for “chip”, “shoo shoo” for “choo choo”
(Child replaces a “ch” or a “j” sound with a “sh, v, f, th, or s”)
INITIAL SCORE
FOLLOW-UP SCORE
7. “pasghetti” for “spaghetti”, “efelant” for “elephant”, “baksit” for “basket”
(Child changes position of a sound within a word)
INITIAL SCORE
FOLLOW-UP SCORE
8. “stuh-reet” for “street”, “fuh-wog” for “frog”, “buh-lue” for “blue”, “puh-lease” for “please”
(Child inserts “uh” into words)
INITIAL SCORE
FOLLOW-UP SCORE
9. “doat” for “goat”, “tuhtie” for “cookie” “tup” for “cup”, “hud” for “hug”
(Child replaces a “k” or a “g” with “t” or “d”)
INITIAL SCORE
FOLLOW-UP SCORE
10. “sue” for “shoe”, “sip” for “ship” “mezza” for “measure”
(Child replaces a “sh” with an “s”)
INITIAL SCORE
FOLLOW-UP SCORE
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Patient Form – Healthy Start

Sleep Disordered Breathing Questionnaire for Children

Earl O. Bergersen, DDS, MSD

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

Speech Questionnaire Further Speech Assessment

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

Specific Articulation Questions

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

GET IN TOUCH

Call us at 416-967-4212 to see how we can help your smile reach its full potential.

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Patient Form – Healthy Start

Sleep Disordered Breathing Questionnaire for Children

Earl O. Bergersen, DDS, MSD

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

Speech Questionnaire Further Speech Assessment

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

Specific Articulation Questions

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounced: 4

Severe: 5

GET IN TOUCH

Call us at 416-967-4212 to see how we can help your smile reach its full potential.