Child Information

age

what are your current concerns regarding your child? Click here to enter text.

Pregnancy and Birth History

child's birth weight

gestational age at birth

other:

length of time in nursery:

If Cesarean, why

other:

were there any problems encountered in Labor and Delivery

were there any difficulties encountered in the first 6 weeks of life? I.e.- feeding, sleeping

Health/Medical History

please give details for those checked including names, dates, concerns, and recommended interventions

please explain

age of onset of seizures:

age at last seizure:

current seizure medication

If yes describe type and recommended interventions

has your child been diagnosed with any medical, psychological, or educational condition?

how would you describe your child’s current state of health?

are there any medical precautions we should know about?

If yes, please list medications and why they have been prescribed.

Sleep/Appetite

other:

what time does your child go to sleep each night?

wake up?

other:

Hearing/Vision

do you have concerns about your child’s hearing?

do you have concerns about your child’s vision?

Family History/information

do any immediate family members have significant medical or developmental concerns?

have there been any major family changes or significant stressors over the last year that might have impacted your child’s development?

Speech/Language Development

what age did they say their first word?

what word?

what age did they begin using single words meaningfully (i.e. to request)?

what age did your child begin babbling?

what age did they use phrases/short sentences?

other:

how many words does your child currently have in their vocabulary?

If yes, please explain:

does your child communicate differently in home and at school or other settings?

DEVELOPMENTAL MILESTONES

Indicate the age when your child first did each of the following INDEPENDENTLY. If your child has not yet achieved the milestone, write N/A in the age column.

Smiled

Held head up

Rolled over

Sat unsupported

Crawled

Pulled to stand

Stood alone

Walked

Ran

Reached for an object actively

Transferred object between hands

Ate unaided with a utensil

Undressed Self

Dressed Self

Bladder trained-days

Bladder trained-nights

Bowel trained

do you have any concerns regarding your child’s motor or self-care development?

how would you describe your child’s play?

what toys/games does your child prefer?

what else would you like us to know about your child?

medical history form

THE VILLAGE THERAPY PLACE
because it takes a village