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)?
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/PDD
other, please explain
Check which is applicable: This is our biological foster adopted child *
Did the mother have medical problems during the pregnancy: yes no*
If yes, please describe, including medical attention:
Was the child full term? yes no*
If no, what was the gestational age?
Were there complications during delivery? yes no*
If yes, explain:
Child’s weight at birth:
Any birth injuries?
What special medication attention or treatment did the child receive at birth, if any?
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 HISTORYMonth/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 noIf 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:
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?
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?Set 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 or 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 How often do you read to your child?
EDUCATIONMy 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