Please provide the name and relationship of the individual completing the form.
INSTRUCTIONS FOR COMPLETING
Please answer the following questions about your child's health and history. Although this form is lengthy, it is designed to be very thorough. Completing this information before your appointment will greatly assist the doctor to best use your assessment time with her/him by enabling a more detailed focus.
If referred by a specific physician, mental health care provider, or other specialist, please provide his/her name, specialty, and contact information below:
Labor and Birth
Infancy and Early Development
Behavioral and Emotional History
Please check all medical conditions that the child has or have had in the past: