*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
Check which is applicable: This is our biological 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
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:
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
Please indicate the month (an estimate is perfectly fine)
-Crawled yes no
Please indicate the month (an estimate is perfectly fine) Type a label
-Stood yes no
-Walked yes no
-Ran yes no
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 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
Does your child snore: Yes No
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
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? occasionally never Does the child prefer to: talk gesture talk gesture Does the child most frequently use: sounds 2-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 -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 p> p>
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?
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)