ABA INTAKE QUESTIONNAIRE

HEALTH AND DEVELOPMENTAL HISTORY
Length of Pregnancy
In Weeks
Birth Weight
blank Lbs. blank Oz.
Please describe any difficulties during pregnancy or delivery.
At what age did child begin to crawl?
blank year(s). blank month(s).
At what age did child begin to walk?
blank year(s). blank month(s).
At what age did child begin to babble?
blank year(s). blank month(s).
At what age did child begin to use single words?
blank year(s). blank month(s).
At what age did child begin to use single sentences?
blank year(s). blank month(s).
At what age did child begin self-feeding?
blank year(s). blank month(s).
Childhood Illness

MeaslesMumpsRubellaChickenpoxRheumatic FeverPolio
Please describe any major medical problems child has experienced.
Please describe any major medical problems in the family.
Is there a history of mental illness in the family?

YesNo
If yes, please describe:

List any medications your child is taking

	Name of Medication	Dose	Frequency taken
1.
2.
3
4.
5.
6.

	Allergies to Medication
1.
2.
3.
4.

	Allergies to Food
1.
2.
3.
4.

Thank you for filling out this questionnaire.
Signature of person filling out the form:

Clear
Relationship to child
Date

MonthDayYear
Date
Should be Empty: