medical history child
The developmental history is an important part of your child’s speech, language and hearing evaluation. Please fill out this form as completely and accurately as possible. Make a note of anything you have questions about and we can discuss them during your appointment.
Person completing this form (*)
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Relationship to child (*)
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Date (*)
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I. IDENTIFICATION
Name (*)
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Birth date (*)
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Mother’s name (*)
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Occupation (*)
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Last grade completed in school (*)
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Father’s name (*)
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Occupation
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Last grade completed in school (*)
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Names of Brothers and Sisters
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Age
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Speech, Hearing or Medical Problems
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II. AREAS OF CONCERN
Please describe why you are having your child seen for a speech-language evaluation
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How does the child usually communicate? (ie: gestures, single words, short phrases, sentences)
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Please give two to three examples of the child’s comments that are typical at this time
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When did you first become concerned?
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Have there been any changes in the condition since you first noticed it?
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Is the child aware of the problem? If so, how does he/she feel about it?
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Have any other speech-language specialists seen the child?
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If Yes, what were their conclusions or suggestions?
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Have any other specialists seen the child?
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If Yes, what type of specialists and what were their conclusions or suggestions?
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Did seeing any of the above mentioned specialists help?
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If Yes, please explain
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Are there any incidences of any of the following conditions among the child’s family and close relatives?
1. Speech Problems
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Please Explain
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2. Hearing Problems
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Please Explain
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3. Learning Disabilities
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Please Explain
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4. Seizures / Convulsions
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Please Explain
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5. Intellectual Disability
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Please Explain
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6. Autism / Spectrum Disorder
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Please Explain
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III. SPEECH, LANGUAGE AND HEARING HISTORY
How much did the child babble and coo during the first 6 months?
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What were the child’s first few words and at what age were they spoken?
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How many words did the child have at 18 months?
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When did the child begin to use two-word sentences?
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Does the child make sounds incorrectly?
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If Yes, which ones?
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How well can the child be understood?(Poorly to Very Well)
By his/her parents
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Comments
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By his/her siblings and playmates
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Comments
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By family friends and relatives
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Comments
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By strangers
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Comments
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Does the child hesitate, “get stuck”, repeat, or stutter on sounds or words?
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If Yes, please describe
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How does the child’s voice sound?
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Did the development of the child’s speech ever slow down or did he/she ever stop talking?
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If Yes, please explain
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Does the child imitate words but not use them?
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If Yes, please explain
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Are there any other languages spoken in the home?
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If Yes, which ones, by whom and how often?
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How well does the child understand what is said to him/her?
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How does the child’s speech compare to those of his/her siblings?
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Does the child have ear infections?
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If Yes, how often?
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Does the child hear adequately?
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If No, please describe
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Does his/her hearing ability fluctuate?
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If Yes, please explain
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Has the child ever worn a hearing aid?
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If Yes, in which ear, for how long have they worn it, and does it seem to help him/her?
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Please check these as they apply to the child
Cried less than normal amount
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If Yes, please explain and give ages if possible
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Laughed less than normal amount
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If Yes, please explain and give ages if possible
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Yelled or screeched to get attention or express annoyance
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If Yes, please explain and give ages if possible
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Head banging and foot stamping
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If Yes, please explain and give ages if possible
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Temper tantrums
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If Yes, please explain and give ages if possible
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Awkward or uncoordinated
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If Yes, please explain and give ages if possible
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Very alert to gestures, facial expression or movement
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If Yes, please explain and give ages if possible
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If Yes, please explain and give ages if possible
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Generally indifferent to sound
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If Yes, please explain and give ages if possible
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Did not respond when spoken to
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If Yes, please explain and give ages if possible
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Responded to noises (car horn, phone) but not to speech
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If Yes, please explain and give ages if possible
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Difficulty using tongue or ‘tongue tied’
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If Yes, please explain and give ages if possible
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Large tongue
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If Yes, please explain and give ages if possible
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Difficulty Swallowing
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If Yes, please explain and give ages if possible
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Gags or chokes easily
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If Yes, please explain and give ages if possible
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Difficulty moving mouth
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If Yes, please explain and give ages if possible
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Drooled excessively
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If Yes, please explain and give ages if possible
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Food came out nose
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If Yes, please explain and give ages if possible
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Talked through nose
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If Yes, please explain and give ages if possible
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Excessive throat clearing
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If Yes, please explain and give ages if possible
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Mouth breathing
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Difficulty breathing
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If Yes, please explain and give ages if possible
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IV. PREGNANCY AND BIRTH HISTORY
Which pregnancy was this child
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Length of pregnancy
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Did any illness, disease and/or accidents occur during pregnancy?
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If Yes, please explain
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Did a blood incompatibility exist between the mother and father?
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Age of mother at infant’s birth
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Age of father at infant’s birth
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Length of labor
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Drugs used during labor
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Were there any problems at birth, ie: breech, caesarean, fever, etc.?
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If Yes, please explain
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Were forceps used?
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Weight of infant at birth
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Child was
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Were there any bruises or scars on the infant’s head?
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Any other abnormalities of the infant’s head or body?
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Did the infant require oxygen following birth?
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Was the child “blue” or jaundiced at birth?
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Was a blood transfusion required at birth?
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Did the infant have a bowel movement before birth?
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If you answered Yes to any of the questions above please explain
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Were there any problems during the first two weeks of life, ie: health, swallowing, sucking, feeding, sleeping, etc.? If so, please explain:
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V. MEDICAL HISTORY
Is the child currently under the care of a doctor (aside from their primary care physician for general checkups)?
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If Yes, please explain
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Is he/she taking medication?
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If Yes, what type and why?
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Please indicate the age at which any of the following occurred and the severity
Adenoidectomy
Age
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Allergies
Age
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Asthma
Age
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Blood disease
Age
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Cataracts
Age
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Chicken Pox
Age
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Chronic Colds
Age
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Convulsions
Age
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Cross-eyed
Age
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Croup
Age
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Dental Problems
Age
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Diphtheria
Age
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Earaches
Age
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Headaches
Age
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Head Injury
Age
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Hearing Problems
Age
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High Fevers
Age
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Influenza
Age
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Mastoidectomy
Age
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Measles
Age
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Meningitis
Age
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Mumps
Age
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Muscle Disorder
Age
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Nerve Disorder
Age
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Orthodontia
Age
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Pneumonia
Age
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Polio
Age
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Rheumatic Fever
Age
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Tonsillectomy
Age
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Whooping cough
Age
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Has the child ever fallen or had a blow to the head?
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If Yes, did he/she lose consciousness?
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VI. BEHAVIOR
Did it cause a concussion?
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Did it cause Nausea, Vomiting or Drowsiness?
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Describe any other illness, injury, operation or physical problem not mentioned above
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Did any of the above require hospitalization?
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If Yes, please explain
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Please indicate which of these apply to the child
Eating problems
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Explain and give ages if possible
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Sleeping problems
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Explain and give ages if possible
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Toilet training problems
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Explain and give ages if possible
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Difficulty Concentrating
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Explain and give ages if possible
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Stays with an activity
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Explain and give ages if possible
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Needs a lot of discipline
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Explain and give ages if possible
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Underactive
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Explain and give ages if possible
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Overactive / Excitable
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Explain and give ages if possible
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Laughed Easily
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Explain and give ages if possible
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Cried a lot
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Explain and give ages if possible
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Sensitive
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Explain and give ages if possible
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Emotional
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Explain and give ages if possible
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Happy
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Explain and give ages if possible
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Irritable
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Explain and give ages if possible
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Personality Problem
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Explain and give ages if possible
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Gets along with children
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Explain and give ages if possible
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Gets along with adults
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Explain and give ages if possible
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Prefers to play alone
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Explain and give ages if possible
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Other
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Explain and give ages if possible
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Does the child separate from his/her parents without crying or fussing?
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How do you discipline the child?
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What are the child’s favorite play activities?
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VII. DEVELOPMENTAL MILESTONES
Please indicate the age at which the following occurred
Rolled over alone
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Sat upright alone
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Crawled
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Stood alone
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Walked unaided
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Fed self with spoon
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Had first tooth
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Dress/undress unaided
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Bladder trained
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Bowel trained
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Toilet trained, waking
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Toilet trained, sleeping
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What hand does the child prefer?
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Has handedness ever changed?
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If Yes, at what age?
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How would you describe the child’s current physical development?
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VIII. EDUCATIONAL HISTORY
List the schools attended/currently attending, please include nursery/preschools
Name
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Ages
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Hours per week
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Name
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Ages
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Hours per week
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Current grade
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Grades skipped
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Grades skipped
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Grades failed
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Average grades
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Best subjects
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Is the child frequently absent from school?
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If Yes, please explain why
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How does the child feel about school and his/her teacher?
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What is your impression of the child’s learning abilities?
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Has anyone ever thought the child has learning problems?
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If Yes please explain:
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Describe any speech, language, hearing, psychological, and special education services that have been performed. Include where and how often
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Thank you for taking the time to fill out this form, please add any additional information you feel will help us in understanding your child and his/her problem
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