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Child's Name_______________________ Birthdate_______________________ Soc. Sec.#____________________
COMPLETE ALL AREA THAT WOULD HELP US IN MEETING YOUR CHILD'S NEEDS. (School Age Children)
HEALTH
Does your child have any physical disabilities? ____________________________________________________________
Any serious illness or hospitilization?____________________________________________________________________
Are there any medications given regularly? _______________________________________________________________
Are there any foods your child cannot eat? ________________________________________________________________
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SOCIAL RELATIONS
Does your child spend tiem with both parents?_____If you are separated, how often does your child see the absent parent? ___________________________ Names and ages of siblings._________________________________________
Has your child had experiences in playing with other children?__________By nature is your child friendly?______________
Aggressive?____________________ Shy?______________ or Withdrawn?__________________
Do you feel your child adjusts easily to a day care situation?_____________Does your child enjoy beign alone?_________
How does yourchild show his/her feelings?_________________________________________________________________
Is your child frightened of any of the following: Animals?________ Dark?________Loud Noises?________Storms?______
Other?_______________________________________________________________________________________________
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PERSONAL HISTORY
Does your child crawl?_________ Walk?_________Is child A Good Climber?_________ Does child fall easily?_________
Has child begun talking?_______ Does Child speak in words?________Or Sentences?_______ Other language?_______
Special words child uses to describe needs? _______________________________________________________________
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TOILET HABITS
Is your child toilet trained?_________ In the process of being trained?_________ Can the child be relied upon to indicate his/her bathroom wishes? _________ Word/Phrase used to indicate "Potty"?_________ Does your child have frequent toilet accidents?_______ What level of assistance does your child need when using the restroom?________________________
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SELF HELP SKILLS
Is your child able to fully dress themselves?___________ Areas needing assistance________________________________
SLEEPING HABITS
Does your child nap?___________ List approximate nap schedule______________________________________________
FEEDINGS
Is your infant on formula?___________ Milk?__________ What is the feeding schedule?_____________________________
Does your child have any dietary restrictions of dislikes?_______________________________________________________
Does your child drink from a cup?______________ Does your child use a spoon?_________________
SCHOOL AGE
What elementary school does your child attend?_____________________________________________________________
Is your child enrolled in any special education or special interest programs?_______________________________________
Describe______________________________________________________________________________________________
Please circle which best describes your child in relation to his/her school experience:
Successfull - Troubled - Difficult - Enjoyable
Where does your child's interest lie? ______________________________________________________________________
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