Child's Doctor:      
Doctor's address:   Street Address   Address Line 2   City   State   Zip        
Do you want a copy of our report sent out to your child's doctor?   Yes   No  


To what other professional persons or agencies do you want a report sent (please provide name/address)?      

*Note: If the Board of Education covers the cost of your child’s evaluation, we can share the report only with your child’s Case Manager. We are not able to send it directly to other professionals or agencies.

Have any members of your immediate family been diagnosed with any of the following: (indicate “F” for father, “M” for mother, or “S” for sibling)
learning disability      
dyslexia      
speech and language delay/disorder      
sensory processing disorder      
auditory processing disorder      
ADD/ADHD      
autistic spectrum disorder      

other, please explain      

Child's health is:   good   fair   poor      
Is the child now under medical treatment or on medication?    yes   no           
If yes, please explain:      

MEDICAL EXAMINATION HISTORY

Month/year of last PHYSICAL EXAM    
Doctor   
Results:      
Month/year of last VISION TEST    
Doctor   
Results:      
Month/year of last HEARING TEST    
Doctor   
Results:      

Did/does child wear a hearing aid?    yes   no           Glasses?   yes   no
If yes, explain:      
Dates of other pertinent medical examinations (e.g., neurological, psychological and ENT):
Date:   Date  Doctor:      
Results:  
Date:   Date  Doctor:      
Results:        
Date:   Date  Doctor:    
Results:        

Did/does the child use a pacifier?   yes   no            
If yes, age weaned from pacifier      
Does the child continue to mouth objects?   yes   no            
Did/does the child suck thumb/fingers?    yes   no             
If yes, until when?      
Does the child suck on hair/clothing/blanket/etc?    yes   no           
If yes, what?      
Did your child meet the following milestones on time?
Sat up   yes      no            Other   
Crawled   yes   no      Other   
Stood   yes   no      Other   
Walked   yes   no      Other   
Ran   yes   no      Other   
Does the child enjoy taking a bath?   yes   no   
Swings?   yes    no   
Large gatherings?     yes   no      
Roughhousing?      yes   no      
Does the child resist toothbrushing?    yes   no          
Child prefers to primarily play:      alone    with other children
Is child overly sensitive to:  
loud sounds   yes   no            
bright lights   yes   no   
tags   yes   no         

My child is:   speaking   non-speaking      
Is the child exposed to more than one language?   yes   no      
If yes, which languages?      
Did child babble during the first 6 months?   Yes   No      
At what age did child say first word?      
What were the child’s first words?      
Did the child keep adding words once he/she started to talk?   Yes   No      
If no, explain:      
At what age did the child begin using 2 and 3-word phrases/sentences?      
Did speech learning ever seem to stop for a period of time?   Yes   No      
If yes, explain:      
Does your child talk a lot?    Please Select occasionally never    
Does the child prefer to:    Please Select talk gesture talk gesture      
Does the child most frequently use:    Please Select sounds single words 2-word sentences 3-word sentences more than 3-word sentences    
List examples:      
Does your child make some sounds incorrectly?   Yes   No      
If yes, which ones?      
Does your child hesitate, “get stuck,” repeat, or stutter on sounds or words?   Yes   No      
If yes, describe:      
Describe any recent changes in the child’s speech:      
Can the child tell a simple story?   yes   no            
How well is he/she understood by the following individuals? (indicate “A” for all the time; “M” for most of the time; “S” for some of the time; or “R” for rarely)
Parents    Please Select A M S R    
Siblings    Please Select A M S R    
Teacher(s)    Please Select A M S R    
Friends    Please Select A M S R    
Strangers    Please Select A M S R    
Comments:      
Does the child seem to understand what you say to him/her?   Yes   No   
If no, explain:      
Does your child consistently answer to his/her name?   Yes   No      
Does your child follow simple commands?   Yes   No      
Please describe/give examples:      
Does your child ever have trouble remembering what you have told him or her?   Yes   No      
If yes, explain:      
Does your child enjoy looking at books?    Yes   No       

Any difficulties breastfeeding and/or bottle feeding?    yes   no    
If yes, please explain:             
Age when weaned off bottle      
Were there any feeding difficulties during infancy?    yes   no           
If yes, describe      
Do you have any concerns regarding the child's weight?   Type a label              
Did your child meet milestones for the introduction of the following foods:
Pureed foods (e.g., rice cereal, Stage 1 jarred)?      
Soft chewables      
Table food      
Did the child have difficulty transitioning to different food textures?   yes   no 
If yes, explain:      
Does your child have a limited diet due to “picky eating?"  yes   no            
If yes, describe:      
Does your child have any food allergies?   yes   no            
If yes, please list:      
Does your child have any known gastrointestinal issues?    yes   no           
If yes, explain:      
Check all that apply: Child   finger feeds    uses fork    spoon    open cup    straw       
Is adult assistance needed with feeding?   yes   no           
If yes, explain:      
Have you ever been concerned with your child's ability to safely swallow solid food?   yes   no            
Does child cough on liquids?    yes   no           
Can child chew well?   yes   no            
Does he/she drool?    yes   no           
If yes, when?      

My child attends:    Please Select Daycare Preschool Kindergarten Grade School    
Name of School          Grade/Level       
In school, my child performs:    Please Select average below average above average    
What are the child’s best subjects?      
Has he or she repeated a grade?   Yes   No            
If yes, which one(s)?      
What is your impression of your child’s learning abilities?      
What is your impression of your child’s social skills?      
Does your child display any behavioral or attentional issues at school?   Yes    no