言語治療專科服務 (十八歲以下人士適用) Speech Therapy Specialty Service (For age under 18)

香港中文大學醫學院耳鼻咽喉—頭頸外科學系歡迎閣下預約本學系的言語治療專科服務。為更了解個案的情況，請家長或監護人填寫本表格。一切所得資料只作臨床參考之用，絕對保密。

閣下填妥表格後，本學系將會盡快處理閣下的服務預約申請，屆時將會通過電話或電郵通知閣下相關的預約資料。

Welcome to the online booking system for Speech Therapy Specialty Service, provided by the Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong. In order to help us better understand your situation, the form should be filled out by parents or legal guardian. All information provided will be kept strictly confidential and available only to persons who are deemed necessary to provide the speech therapy service.

After receiving your application, we will process it as soon as possible and contact you via phone/email shortly.

兒童資料 Child’s Personal Information
兒童姓氏 Child's Surname
兒童名字 Child's First Name
出生日期 Date of birth 出生日期 Date of birth / DD / MM YYYY
年齡 Age
性別 Gender

性別 Gender 男 Male 女 Female
聯絡人姓名及關係
Contact Person Name & Relationship*
聯絡電話 Contact Phone Number
其他聯絡電話 Alternate Contact Phone Number
電郵 Email address
父親的教育程度 Father's Education Level
父親之職業 Father's Occupation
母親的教育程度 Mother's Education Level
母親之職業 Mother's Occupation
兒童的母語為： Child's first language/mother tongue:

兒童的母語為： Child's first language/mother tongue: 廣東話 Cantonese 普通話 Mandarin 英語 English 其他 Other 其他 Other
兒童之主要照顧者為：
The child's primary care giver:
兒童之主要照顧者以何種語言與兒童溝通
The language(s) of the child's primary caregiver communicate with the child:

兒童之主要照顧者以何種語言與兒童溝通The language(s) of the child's primary caregiver communicate with the child: 廣東話 Cantonese 普通話 Mandarin 英語 English 其他 Other 其他 Other
兄弟姊妹數目，如沒有請填：沒有
Number of sibling, please type: N/A
兄弟姊妹的年齡
Siblings's age
兄弟姊妹是否有發音、語言、或聽力問題，請加以說明
Do they have speech, language or hearing problems, please describe
出生及健康史 Birth and Health History
懷孕週數 Gestational period
生產方法 Method of delivery

生產方法 Method of delivery 順產 Natural Labour 開刀 Caesarean section
出生後健康是否大致正常？
Is your child’s health generally normal?

出生後健康是否大致正常？Is your child’s health generally normal? 是 Yes 否 No
如否，請略述情況
If not, please describe
兒童是否曾患過嚴重疾病?
Has your child ever had any serious illnesses?

兒童是否曾患過嚴重疾病?Has your child ever had any serious illnesses? 是 Yes 否 No
如是，請略述情況
If yes, please describe
兒童是否需要定期到專科覆診
Does your child need to see a healthcare specialist or doctor regularly?

兒童是否需要定期到專科覆診Does your child need to see a healthcare specialist or doctor regularly? 需要 Yes 不需要 No
如是，請提供專科名稱
If yes, please provide the profession of the specialist
發展史 Developmental History
兒童何時懂得坐?
When did your child sit independently?
兒童何時懂得走路？
When did your child be able to walk?
兒童何時懂得說單字，如爸、媽、車？
When did your child be able to use single words? such as mum, dad, car?
兒童是否曾接受語言能力評估？
Has your child had any assessment/evaluation on speech and language ability?

兒童是否曾接受語言能力評估？Has your child had any assessment/evaluation on speech and language ability? 是 Yes 否 No
請提供評估日期please provide the date of the assessment/evaluation 請提供評估日期
please provide the date of the assessment/evaluation / DD / MM YYYY
請提供評估地點
Please provide the location of the assessment/evaluation
請提供負責人之名稱
Please provide the name of examiner
請提供評估結果
Please provide the results of the assessment
如有評估報告，請上載於此
If assessment/evaluation report had been collected, please upload here

Attach Files

每次只可傳送五個檔案，每個檔案限制為5MB

Up to five files can be uploaded. The maximum size of the file is limited to 5 MB.
兒童接受評估後，是否曾接受治療？
Has your child had any speech and language treatment after the assessment/evaluation?

兒童接受評估後，是否曾接受治療？Has your child had any speech and language treatment after the assessment/evaluation? 是 Yes 否 No
請提供治療開始日期please provide the date that therapy started 請提供治療開始日期
please provide the date that therapy started / DD / MM YYYY
如有治療進度報告，請上載於此
If report had been collected, please upload here

Attach Files

每次只可傳送五個檔案，每個檔案限制為5MB

Up to five files can be uploaded. The maximum size of the file is limited to 5 MB.
兒童是否曾接受智能測驗？
Has your child had any intelligence (IQ) test?

兒童是否曾接受智能測驗？Has your child had any intelligence (IQ) test? 是 Yes 否 No
請提供測驗日期Please provide the date of the test 請提供測驗日期
Please provide the date of the test / DD / MM YYYY
請提供測驗地點
Please provide the location of the test
請提供測驗結果
please provide the results of the test
如有測驗報告，請上載於此
If test report had been collected, please upload here

Attach Files

每次只可傳送五個檔案，每個檔案限制為5MB

Up to five files can be uploaded. The maximum size of the file is limited to 5 MB.
教育史 Educational Information
兒童現正就讀學校的名稱
The name of child's current school
兒童所就讀之班級
The school grade of child
教師的評語
Teacher's comments
言語及語言困難的情況 Speech and Language Difficulties
是次求診原因 (可選擇多於一項)：
Reason of consultation (please check all that apply):

是次求診原因 (可選擇多於一項)：Reason of consultation (please check all that apply): 咬字發音困難 Speech Sound Difficulties 語言困難 Language Difficulties 口吃 Stuttering 讀寫困難 Reading and Writing Difficulties 自閉症徵狀 Autistic Spectrum Disorder 聲線問題 Voice Problems 聽覺障礙 Hearing difficulties 吞嚥困難 Swallowing Difficulties 其他 Other 其他 Other
咬字發音錯誤的例子
Examples of Speech Sound Errors

例如: 手->抖, 狗->豆, 濕->汁；如發不到s音

For example: cup-> tup, spoon ->poon; cannot imitate /s/ sound
眼神接觸 Eye Contact

眼神接觸 Eye Contact 良好 Very Good 一般 Average 不理想 Not Appropriate
專注力 Attention Span

專注力 Attention Span 良好 Very Good 一般 Average 不理想 Not Appropriate
現階段表達能力
Current ability of verbal expression

現階段表達能力 Current ability of verbal expression BB話 Babbling (ba ba da da) 單字 Single Words 短句 Short Sentences 完整句子 Complete Sentences 敘事 Narrative/ Story telling 其他 Other 其他 Other
印象中兒童所說過最長的句子
The longest sentences that your child has said
現階段理解能力
Current ability of verbal understanding

現階段理解能力Current ability of verbal understanding 單字 Single Words 短句 Short sentences 完整句子 Complete Sentences 敘事 Narrative/ Story 其他 Other 其他 Other
問句理解 Understanding of question types

問句理解 Understanding of question types 有無(有沒有) 係唔係(是不是) Yes or No 乜野(甚麼) What 邊度(哪裡) Where 邊個(誰) Who 點解(為甚麼) Why 點樣(為何) How 其他 Other 其他 Other
口吃 Stuttering

口吃 Stuttering 重複字詞 Repeats sounds/word 句子停頓 Stops in the middle of sentence 拖長字詞 Drags or prolongs certain sounds 面部歪扭 Facial grimaces when talking 其他 Other 其他 Other
聲線問題 Voice Problem

聲線問題 Voice Problem 沙啞 Hoarse/rough voice 失聲 Loss of voice 聲線疲勞 Fatigue Voice 其他 Other 其他 Other
左耳聽力程度 Left Ear Hearing Level

左耳聽力程度 Left Ear Hearing Level 不詳 unknown 正常 Normal 輕度聽障 Mild Loss 中度聽障 Moderate Loss 中度至嚴重聽障 Moderate to Severe Loss 嚴重聽障 Severe Loss 深度聽障 Profound Loss
左耳聽力儀器 Left Ear Hearing Device

左耳聽力儀器 Left Ear Hearing Device 沒有 Nil 佩戴助聽器 Wearing Hearing Aid 佩戴人工耳蝸 Wearing Cochlear Implant 其他 Other 其他 Other
右耳聽力程度 Right Ear Hearing Level

右耳聽力程度 Right Ear Hearing Level 不詳 unknown 正常 Normal 輕度聽障 Mild Loss 中度聽障 Moderate Loss 中度至嚴重聽障 Moderate to Severe Loss 嚴重聽障 Severe Loss 深度聽障 Profound Loss
右耳聽力儀器 Right Ear Hearing Device

右耳聽力儀器 Right Ear Hearing Device 沒有 Nil 佩戴助聽器 Wearing Hearing Aid 佩戴人工耳蝸 Wearing Cochlear Implant 其他 Other 其他 Other
吞嚥困難 Swallowing Difficulties

吞嚥困難 Swallowing Difficulties 不願進食 Not willing to eat 進食緩慢 Slow eater 進食時流口水 Drools while eating 需要鼻管或胃管餵食
Feeds with nasogastric tube/PEG 飲食時較易“濁”到 Coughs/chokes while eating 其他 Other 其他 Other
其他言語或語言困難的詳細情況
Details of Other Speech or Language Difficulties
預約資料 Booking Details
希望評估以何種語言進行
Preferred language(s) for the consultation

希望評估以何種語言進行Preferred language(s) for the consultation 廣東話 Cantonese 普通話 Mandarin 英語 English
希望約見的診所 Preferred Specialty Clinic:

希望約見的診所 Preferred Specialty Clinic: 動態評量及認知治療診所 Dynamic assessment and Mediated Learning Experience Clinic 流暢障礙診所 Fluency Disorders Clinic 腭裂及顱面異常診所 Cleft Palate & Craniofacial Anomalies Clinic 聽力障礙診所 Hearing Impairment Clinic 神經性溝通障礙診所 Neurogenic Communication Disorders Clinic 自閉症譜系障礙之社交溝通障礙診所 Social Communication Deficits of People with Autism Spectrum Disorder Clinic 吞嚥障礙診所 Dysphagia Clinic 聲線障礙診所 Voice Disorders Clinic 語音障礙診所 Speech Sound Disorders Clinic 第二方診療意見診所 Tertiary Assessment Clinic 言語治療碩士課程學生診所 MSc Speech-Language Pathology Student Clinic 沒有偏好 No Preference
希望約見的言語治療師 Preferred Speech Therapist

希望約見的言語治療師 Preferred Speech Therapist 李月裳教授 Professor Kathy LEE 羅家東教授 Professor Thomas LAW Professor Valerie PEREIRA 方思行教授 Professor Raymond FONG 胡韞儀小姐 Ms Yunyi HU 簡沛淇小姐 Ms Peggy KAN 關靜然小姐 Ms Connie KWAN 林玉秋小姐 Ms Emily LAM 韋一鳳小姐 Ms Phoenix WEI 言語治療碩士課程學生 MSc Speech-Language Pathology Student 任何一位治療師皆可 Any Speech Therapist
診療模式 Consultation Format

診療模式 Consultation Format 面授 Face-to-Face 網上 Online
希望預約的時間 Preferred Time

希望預約的時間 Preferred Time 星期一上午 Monday AM 星期一下午 Monday PM 星期二上午 Tuesday AM 星期二下午 Tuesday PM 星期三上午 Wednesday AM 星期三下午 Wednesday PM 星期四上午 Thursday AM 星期四下午 Thursday PM 星期五上午 Friday AM 星期五下午 Friday PM 任何時間 Any Time

服務時間為星期一至五：早上9時至下午5時(最後診症時間為下午4時，星期六、日及公眾假期休息。

Our service opens at 9:00 and closes at 17:00 (last appointment time is 16:00) from Mon-Fri. Saturdays, Sundays and public holidays closed.
對是次諮詢的期望(必須填寫)
What are your expectations of the consultation? (Required)
額外資料(如適用)
Additional information (if applicable)

任何想提供的資料

Any information you would like to provide
如有轉介信，請上載於此欄
Please upload if you have a referral letter

Attach Files

每次只可傳送一個檔案，每個檔案限制為5MB

Multiple files are not allowed. The maximum size of the file is limited to 5 MB.
從何處認識我們的服務?
Where do you know our service?

從何處認識我們的服務?Where do you know our service? 私人執業醫生轉介 Referred by private doctors 公營機構醫生轉介 Referred by Hospital Authority or Department of Health doctors 香港中文大學耳鼻喉科醫生轉介 Referred by ENT doctors, CUHK 香港中文大學保健處轉介 Referred by UHS, CUHK 香港中文大學醫院轉介 Referred by CUHK Medical Centre 親友、同事或朋友介紹 Introduced by Relatives, colleagues or friends 學校 Schools 香港言語治療師協會網頁 The Hong Kong Association of Speech Therapists Website 其他網頁 Other Website 面書 Facebook 報章雜誌 Newspaper & Magazine 其他 Other 其他 Other
是否同意讓言語治療碩士課程學生觀察兒童的診療過程?
Do you agree to let MSc Speech-Language Pathology students observe your child's session?

是否同意讓言語治療碩士課程學生觀察兒童的診療過程?Do you agree to let MSc Speech-Language Pathology students observe your child's session? 同意讓學生在診療室內觀察 Agree students to observe it in the clinic room 同意讓學生透過視像系統在診療室外觀察 Agree students to observe it through Observation System outside the clinic room 同意讓學生在診療室內觀察及透過視像系統在診療室外觀察 Agree students to observe it in the clinic room and through Observation System outside the clinic room 不同意 Disagree
是否同意讓言語治療碩士課程學生於診療室內協助言語治療師進行診療過程?
Do you agree to let MSc Speech-Language Pathology students assist our speech therapist to conduct your child's session in the clinic room ?

是否同意讓言語治療碩士課程學生於診療室內協助言語治療師進行診療過程?Do you agree to let MSc Speech-Language Pathology students assist our speech therapist to conduct your child's session in the clinic room ? 同意 Agree 不同意 Disagree
是否願意登記以接收有關我們最新活動的電郵?
Are you willing to receive the email regarding our latest activities?

是否願意登記以接收有關我們最新活動的電郵?Are you willing to receive the email regarding our latest activities? 現在登記 Register Now 不登記 Will not register  已登記 Already Registered
收集個人資料聲明
Personal Information Collection Statement

閣下所提供的資料只用於言語治療服務相關之用途。閣下有權要求查閱及更正你的個人資料，有關要求請向言語治療科提出。當我們獲得閣下的個人資料後，會把這些資料妥善地儲存在系統中，只有授權之職員方可讀取這些個人資料。我們亦保證本科職員對閣下的個人資料作高度保安及保密。

The Department will use the information provided by you for Speech Therapy related services only. You have the right to request access to and correction of your personal data. Please contact Division of Speech Therapy for the above requests. Once we have obtained your personal data, they will be maintained securely in our system. Only authorised staff will be permitted to access to such personal data. We will also ensure compliance by our staff with the strictest standards of security and confidentiality.
聲明 Declaration

聲明 Declaration 我已經閱讀及理解以上聲明並同意遵守。
I declare that I have read and understood the above statement and I agree to abide by it.
Disclaimer The personal data collected will be used by Dept of Otorhinolaryngology, Head and Neck Surgery_ENT-ST Division - MED (OHNS_ENT_MED) and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.

言語治療專科服務 (十八歲以下人士適用) Speech Therapy Specialty Service (For age under 18)

兒童資料 Child’s Personal Information

出生及健康史 Birth and Health History

發展史 Developmental History

教育史 Educational Information

言語及語言困難的情況 Speech and Language Difficulties

預約資料 Booking Details

收集個人資料聲明Personal Information Collection Statement

收集個人資料聲明
Personal Information Collection Statement