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)?
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? Yes No* If yes, explain: What special medical 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 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 SKILLSMy 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 DEVELOPMENTMy 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:
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 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)