Title Page

  • Child's name

  • Gender

  • Age

  • Child's birthdate

  • Attending Physician

  • Date Conducted

General Information

  • Form filled out by

  • Relation to the child

  • Please specify relation to child

  • Does the child have any illness or disability (either physical or mental)?

  • Please describe

  • What concerns you most about the child?

  • Please describe the best things about the child

Language Development

  • Was the child born earlier than the usual 9 months after conception?

  • How many weeks early?

  • How much did the child weigh at birth? (provide information in pounds, ounces or grams)

  • How many ear infections did the child have before the age 24 months?

  • Is any language besides English spoken in the child's home?

  • specify the languages

  • Has anyone in the child's family been slow in learning to talk?

  • please list their relationship to the child (i.e brother, father)

  • Are you worried about the child's language development?

  • If yes, why?

  • Does the child spontaneously say words in any language (not just imitates or understands words)?

  • Does the child combine 2 or more words into phrases? (i.e "more cookie," "car bye-bye")

  • Please print 5 of the child's longest and best phrases or sentences. (For each phrase that is not in english, print the name of the language.)

General Behavior

  • Acts too young for his/ her age

  • Afraid to try new things

  • Avoids looking others in the eye

  • Trouble concentrating or can't pay attention for a longer time

  • Can't stand waiting; wants everything now

  • Can't sit still, restless or hyperactive

  • Clings to adults or too dependent

  • Constantly seeks help

  • Constipated, doesn't move bowels (not when sick)

  • Cries a lot

  • Cruel to animals

  • Defiant

  • Doesn't want to sleep alone

  • Doesn't answer when people talk to him/ her

  • Disturbed by any change in routine

  • Destroys his/ her or others things on purpose

  • Doesn't eat well

  • Don't get along with other kids

  • Doesn't feel any guilt after misbehaving

  • Easily jealous

  • Fears certain animals, situations or places other than school

  • Feelings are easily hurt

  • Gets hurt a lot, accident-prone

  • Gets in many fights

  • Hits others

  • Angry moods

  • Holds his/ her breath

  • Looks unhappy without good reason

  • Nervous movements or twitching

  • Nightmares or Night terrors

  • Overeating

  • Overtired

  • Shows panic for no good reason

  • Painful bowel movements (without medical cause)

  • Picks nose, skin, or other parts of body

  • Poorly coordinated or clumsy

  • Plays with own sex parts too much

  • Screams a lot

  • Selfish or won't share

  • Shows little affection toward people

  • Too shy or timid

  • Sleeps less than most kids during day and/ or night

  • Stubborn, sullen, or irritable

  • Sudden changes in mood or feelings

  • Too fearful or anxious

  • Uncooperative

  • Wakes up often at night

  • Wanders away

  • Others that were not mentioned

  • Behavior
  • Define behavior

  • Rate behavior

Completion

  • Name & Signature of Parent/Caregiver

  • Name & Signature of Attending Physician

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