Test

Prenatal and Birth History
Mother's general health during pregnancy (illnesses, accidents, medications, etc.)*
Length of Pregnancy*
Length of Labor*
General Condition*
Birth Weight*
Type of Delivery*
Were there any unusual conditions that may have affected the pregnancy or birth?*

Medical History
Provide the approximate ages at which the child suffered the following illnesses and conditions:
Allergies*
Asthma*
Chicken Pox*
Colds*
Convulsions*
Croup*
Dizziness*
Draining Ear*
Ear Infections*
Encephalitis*
German Measles*
Headaches*
High Fever*
Influenza*
Mastoiditis*
Measles*
Meningitis*
Mumps*
Pneumonia*
Seizures*
Sinusitis*
Tinnitus*
Tonsilitis*
Other*

Developmental History
Provide the approximate age at which the child began to do the following activities:
Crawl*
Sit*
Stand*
Walk*
Feed Self*
Dress Self*
Is your child toilet trained? Is yes, how old was your child when toilet trained?*
Is your child a picky eater?*
Does your child show hand dominance?*
Does your child fall frequently?*
Use single words? (e.g. no, mom, doggie, etc.)*
Combine words? (e.g. me go, daddy shoe, etc.)*
Name simple objects? (e.g. dog, car, tree, etc.)*
Use simple questions? (e.g. Where's doggie?, etc.)*
Engage in conversation?*

Does your child have difficulty walking, running, or participating in other activities which require small or large muscle coordination?*
Are there or have there been any feeding problems (e.., problems with sucking, swallowing, drooling, chewing, etc.)? If yes describe:*
Is your child on a special diet?*
Does your child have food allergies?*
Describe your child's response to sound (e.g., responds to all sounds, responds to loud sounds only, inconsistently responds to sound, etc.):*

Education History
School*
Grade/Class*
Teacher(s)*
How is your child doing academically (or pre-academically)?*
Does the child receive special services? If yes, describe classroom.*
How does the child interact with others? (e.g., shy, aggressive, uncooperative, etc.)*
If enrolled for special education services, has an individualized Education Plan (IEP) been developed? If yes, describe the most important goals.*
Provide additional information that might be helpful in the evaluation or remediation of the child's problem:*
Did your child attend Early Intervention?*
- Yes
- No
Did your child attend Pre-School?*
- Yes
- No
Did your child attend Kindergarten?*
- Yes
- No
Any grades repeated?*
Signature
Name*
Date*
MM slash DD slash YYYY

General Information