VMB Development, Inc. Questionnaire
Child
(Print Childs name)
Parent Signature:
Today's Date:
-
Month
-
Day
Year
Date
When Are Glasses or Contacts Worn:
Provide All Medical Diagnosis' Child Currently Has:
Below, Please Give a Short Description of Child's Current Ability To:
Read/Comprehend/Learn In School
Have Motivation & Willingness to Learn, Think & Participate
Communicate
Participate In Physical Activity (Running, Skipping, Hopping)
Do Chores
Hold A Pencil Or Crayon & Have Good Handwriting
Focus / Have Patience
Remember (Short or Long Term)
Have Self Confidence
Follow More Than One Direction At A Time
Have Coordination
Concentrate / Pay Attention
Do Chores & Willingness
Behave Good
Sleep
Multitask
Use Sensory Skills (Smell, Touch, Vision, Hearing, Taste & Balance)
Maintain Eye Contact With Person Speaking With
Preview PDF
Submit
Should be Empty: