CHILD’S NAME_____________________________________________________

DATE OF BIRTH_______________

PERSONAL HISTORY:

TYPE OF BIRTH_______________________________________

ANY COMPLICATIONS?______________________

AGE BEGAN SITTING_____________

CRAWLING_____________

WALKING_____________

TALKING___________

ANY SPEECH DIFFICULTIES?

_____________________________

SECOND LANGUAGE?_____________________

HEALTH:

ANY SERIOUS ILLNESS OR HOSPITALIZATION?________________________________________________

ANY DISABILITIES?

_________________________________________________

IS YOUR CHILD ON REGULAR MEDICATION?

____________________

IF SO WHAT_________________________

EATING:

DOES YOUR CHILD HAVE ANY EATING PROBLEMS?

_________________________________________________

ANY FOOD ALLERGIES?

___________________________

FAVORITE FOODS

_______________________________

TOILET HABITS:

CAN YOUR CHILD INDICATE BATHROOM NEEDS?

__________________

WORD FOR URINATION_________________________

WORD FOR BOWEL MOVEMENT____________________

DOES YOUR CHILD HAVE FREQUENT “ACCIDENTS”? ___________

IS YOUR CHILD WEARING DIAPERS OR “PULL-UPS”?____________

SLEEPING HABITS:

DOES YOUR CHILD NAP DAILY?

_____________

IF SO, WHEN?

________________

DO YOU PREFER THAT YOUR CHILD NAP AT SCHOOL OR IS A QUIET TIME OKAY?

______________

SOCIAL RELATIONSHIPS:

DOES YOUR CHILD PLAY WITH PEERS IN YOUR NEIGHBORHOOD?

____________________

IS YOUR CHILD:

AGGRESSIVE/PHYSICAL?_______________

QUIET/SHY?_______________

HAPPY/CONTENT?_______________

DO YOU ANTICIPATE SEPARATION PROBLEMS WHEN YOUR CHILD BEGINS SCHOOL?___________________

HOW DO YOU DISCIPLINE YOUR CHILD AT HOME?_________________________________________________

WHAT IS YOUR CHILD’S FAVORITE ACTIVITIES?

_________________________________________________