Child’s Name______________________________Male_____Female_____ Date of Birth ____________

Address:__________________________________City:___________Zip:_______ Phone: ___________

Mother’s Name:____________________________Occupation:____________ Work Phone:__________

Father’s Name:_____________________________Occupation:____________Work Phone: _________ 

Step-parent’s Name:_________________________Occupation:____________Work Phone: _________

Child’s Home School: (School child will attend in Kindergarter__________________________________

Languages Spoken at Home:___________________ Child’s Primary Language:___________________

Ethnicity:(circle one)   White    Black     Hispanic    Native American    Asian     Other _______________

Who is completing this form:___________________________ Relationship to child:________________

What is your primary concern regarding your child’s development?_____________________________

___________________________________________________________________________________

___________________________________________________________________________________

Birth History

Child’s weight at birth _________ Was the baby full term?__________ If not, how many weeks?______

Were there any complications during pregnancy? YES /NO Explain: (Ex. illness, injury, preterm
labor, etc.)
___________________________________________________________________________________

Were there any complications during birth? YES /NO Explain: (Ex. breech, instruments needed,
C-section)
___________________________________________________________________________________

Were there any complications after birth? YES /NO Explain: (Ex. jaundice, respiratory infections,
feeding difficulties)
___________________________________________________________________________________

Were there any other conditions present during or after birth that you feel were significant? _________

___________________________________________________________________________________

___________________________________________________________________________________

Family History

Please list siblings and ages:

Name:__________________________  Age:___ Name:_____________________________  Age:___

Name:__________________________  Age:___ Name:_____________________________  Age:___

Name:__________________________  Age:___ Name:_____________________________  Age:___

Who does child reside with including all members in the household? (Ex. siblings, step-parents, grandparents, etc.)
___________________________________________________________________________________

___________________________________________________________________________________

Have any family members, including extended family experienced any of the following:
(Describe relationship to child)

Developmental Delays YES / NO Explain:__________________________________________________

Speech and Language Problems YES / NO

Explain:_____________________________________________________________________________

Learning Difficulties YES / NO Explain:____________________________________________________

Medical History

Physician’s Name:______________________Phone:__________Date of last check-up?____________

How would you describe your child’s health?      EXCELLENT        GOOD           FAIR          POOR

Has your child had a history of the following:

Chronic Ear infections  YES /NO How frequent?______________ Describe treatment:______________

Allergies YES /NO What is your child allergic to?_________________ Treatment?_________________

Accidents YES /NO   Describe:__________________________________________________________

___________________________________________________________________________________

Chronic Colds YES /NO  How often? _____________________________________________________

Respiratory Illnesses? YES /NO  Describe: ________________________________________________

High Fevers YES /NO How often?  Explain: ________________________________________________

Seizures YES /NO    Explain:____________________________________________________________

Head Injuries YES /NO   Explain: ________________________________________________________

Serious Illnesses YES /NO    Describe:____________________________________________________

Surgeries YES /NO   Explain:____________________________________________________________

Hospitalizations YES /NO   Explain: ______________________________________________________

Is there any other medical information you think is important regarding your child? ________________

___________________________________________________________________________________

List any medications your child is currently taking   __________________________________________

___________________________________________________________________________________

Educational History

Is your child currently attending a PRESCHOOL program? YES /NO Where?____________________

How often does your child attend this program? ____________________________________________

Has your child attended a PRESCHOOL program in the past? YES /NO

Where?__________________________________When?______________________

How often did your child attend this program?______________________________________________

Is your child currently receiving CHILD CARE from someone other than parents? YES /NO

If YES: Is your child attending: HOME DAY CARE / DAY CARE FACILITY

How often does your child receive child care?______________________________________________

Child Care Provider’s Name:_____________________________________Phone:_________________

Has your child ever received the following:

Speech and Language Evaluation  YES /NO   Where?__________________ When?_____________

Results: ____________________________________________________________________________

Speech and Language Therapy  YES /NO Where? _____________________  When?____________

Hearing Evaluation YES /NO Where?____________________________ When?_________________

Results: ____________________________________________________________________________

Vision Evaluation YES /NO  Where?_____________________________ When?_________________

Results:_____________________________________________________________________________

Developmental Screening/Evaluation  YES /NO   Where?_________________When?____________

Results:_____________________________________________________________________________

Psychological Evaluation  YES /NO Where?_______________________  When?________________

Results:_____________________________________________________________________________

Occupational Therapy YES /NO Where?__________________________ When?________________

Physical Therapy YES /NO   Where?______________________________ When? _______________

Any other evaluations or services your child has received?____________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Language Development

At what age did your child speak his/her first word?__________________What was that word? ______

At what age did your child use: Two words together?________________Speak in sentences? _______

Does your child communicate using gestures? YES /NO Examples:   ____________________________

Give examples of some things your child might say: _________________________________________

Does anyone have difficulty understanding your child’s speech? YES /NO  Explain:________________

Are you concerned about your child’s fluency (stuttering)? YES /NO    Explain:____________________

___________________________________________________________________________________

Did your child ever start talking and then stop? YES /NO    Explain:______________________________

Does your child understand when he is spoken to? YES /NO    Example:_________________________

Is your child able to follow simple directions? YES /NO    Example:______________________________

Social/Emotional Development

Describe how your child plays with other children?__________________________________________

Describe how your child shares toys with other children?_____________________________________

Does your child engage in an activity for a reasonable length of time? YES /NO Example:___________

Does your child become easily frustrated? YES /NO Example:_________________________________

Does your child separate from you easily? YES /NO Explain:__________________________________

Does your child have extreme fears? YES /NO   Example:_____________________________________

Does your child have frequent tantrums? YES /NO   Example:__________________________________

Do you have concerns regarding your child’s behavior?______________________________________

Other information you would like to share regarding your child’s social and emotional development?

___________________________________________________________________________________
Physical Development

At what age did your child: Sit up unassisted_____________Crawl _____________Walk____________

Does your child prefer one hand over the other? YES /NO LEFT     RIGHT

Does your child have any weakness in arms or legs? YES /NO Explain: _________________________

Does your child like to run? YES /NO

Does your child pedal a tricycle, big wheel, or bike? YES /NO

Does your child use markers or crayons to make marks on paper? YES /NO

Do you consider your child clumsy or showing poor control of body movements? YES /NO Explain:

__________________________________________________________________________________

Adaptive Behavior Development (Self Help Skills)

Is your child toilet trained? YES /NO  DAYTIME / NIGHTTIME Explain________________________

Does your child feed her/himself? YES /NO    FINGER FOOD / UTENSILS

Does your child drink from a cup without spilling? YES /NO     TIPPY CUP / REGULAR CUP

Does your child dress her/himself? YES /NO   PARTIALLY / COMPLETELY

Describe the things about your child’s development that please you the most_____________________

__________________________________________________________________________________