Child's Doctor:          
Doctor's Address:    Street Address   Address Line 2   City   State   Zip          
Do you want a copy of our report sent to your child's doctor?    Yes   No             
To what other professional persons or agencies do you want a report sent (please provide name/address)?      

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:        

Were there any feeding difficulties during infancy?   Yes   No         
If yes, describe      
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:      
Has he/she ever choked on solid foods?   Yes   No         
Does child cough on liquids?     Yes   No          
Can child chew well?   Yes   No         
Does he/she drool?   Yes   No           
If yes, when?      

Give the ages at which the following first occurred:
Sat up      
Crawled      
Stood   
Walked      
Ran      
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?      
Does the child enjoy taking a bath?   Yes   No   
Swings?   Yes   No   Parties   Yes   No   Roughhousing?   Yes   No      
Does the child resist toothbrushing?   Yes   No      
Child prefers to primarily play:   alone   with other children   with older children   with younger children   with adults      
Is child overly sensitive to:
Loud sounds?   Yes   No      
Bright lights   Yes   No   
Tags   Yes   No         
Does your child have difficulty:
Falling asleep?   Yes   No      
Staying asleep?   Yes   No      
Check all that apply:   Child finger feeds    uses fork    spoon    open cup    straw      
Is adult assistance needed with feeding?   Yes   No      
If yes, explain      
Is the child toilet trained?   Yes   No      
If yes, at what age was he/she:    
Bladder trained      
Bowel trained      
Night trained      
Check all that your child can do independently:   put on jacket   pants    shirt    socks    shoes   button    zip    tie shoes   
Which hand does the child use more frequently?   Right   left   No preference     

PLAY SKILLS
My child can play independently:   rarely   occasionally   often   
Does your child take part in playgroups/play socially with peers?   

At an age-appropriate level, my child knows:
colors   yes   no   some      
shapes   yes   no   some      
letters   yes   no   some      

Child can:
play imaginatively   yes   no              
complete a puzzle   yes   no      
cut with scissors   yes   no      
write his/her name   yes   no      
color/draw   yes   no      

SPEECH, LANGUAGE AND HEARING DEVELOPMENT
My child is   Speaking   Non-speaking      
Child babbled 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    
Is your child difficult to understand?  Yes   No      
If yes, explain      
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 make appropriate eye contact with adults?    Yes   No      
Other children?   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:      

EDUCATION
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     
If yes, explain:      
Does your child participate in extracurricular activities?   Yes   No      
If yes, please list:      
What are your child's favorite interests (e.g. favorite TV show, toys, characters, movies, subjects)